Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 201909-0938-001 · OMB 0938-0842.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0842 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10036 IRF- PAI vesion 4.0 Inpatient Rehabilitation Facility - Patient Assessment Instrument	Form and Instruction
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf	Instruction
CMS-10036 IRF- PAI vesion 4.0 IRF-PAI Version 4.0 - Effective October 1 2020.pdf	Form and Instruction
IRF-PAI Version 4.0 Change Table - Effective October 1, 2020.docx Change Table for Proposed IRF QRP New and Modified Items	IC Document

IC Title:

Inpatient Rehabilitation Facility - Patient Assessment Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10036				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Inpatient Rehabilitation Facility - Patient Assessment Instrument

FR Citation: 71 FR 67143

Number of Respondents: 1,122

Number of Respondents for Small Entity: 194

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	411,081	7,740	403,341
Annual IC Time Burden (Hours)	704,747	607,329	97,418
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Change Table for Proposed IRF QRP New and Modified Items		10/03/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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