Crosswalk

---

Overview

FASI Set
FASI Training

---

Sheet 1: FASI Set

2016 (old version)	2019 (new version)	Type of Change	Reason for Change	Burden Change
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1037. The time required to complete this information collection is estimated to average 30 minutes per response. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.	PRA Disclosure Statement: This information is being collected to assist the Centers for Medicare & Medicaid Services (CMS) with standardizing functional assessment items for home and community based services (HCBS) and develop performance measures. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0938-1037 (Expires: TBD). The SORN is 09-70-0569.	Rev	Added purpose of data collection and streamlined language	No
Section A: Assesor certification statements	Removed	Del	Not Necessary	No
Self-Care Priorities: Please indicate your top two priorities in the area of mobility for the next six months.	Self-Care Priorities: Please ask the person to describe at least one or two personal priorities in the area of self-care for the next six months. If the person does not express any personal priorities in this area, please note this below.	Rev	Based on Round 1 Testing, revised instructions	No
Mobility Priorities: Please indicate your top two priorities in the area of mobility for the next six months.	Mobility Priorities: Please ask the person to describe at least one or two personal priorities in the area of mobility for the next six months. If the person does not express any personal priorities in this area, please note this below.	Rev	Based on Round 1 Testing, revised instructions	No
IADL Priorities: Please indicate your top two priorities in the area of instrumental activities of daily living for the next six months.	IADL Priorities: Please ask the person to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the person does not express any personal priorities in this area, please note this below.	Rev	Based on Round 1 Testing, revised instructions	No
Living Arrangement and Caregiving Priorities: Please indicate your top two priorities in the area of living arrangements and caregiving for the next six months.	Living Arrangement Priorities: Please ask the person to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the person does not express any personal priorities in this area, please note this below. Caregiving Priorities: Please ask the person to describe at least one or two personal priorities in the area of caregiving for the next six months. If the person does not express any personal priorities in this area, please note this below.	Rev	Based on Round 1 Testing, revised instructions and split Living Arrnagement and Caregiving Prioriies	No
IADL List 11k. Simple financial management: The ability to complete financial transactions such as counting coins, verifying change for a single item transaction or writing a check.	11k. Simple financial management: The ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.	Rev	Based on Round 1 Testing, added examples for clarity	No
Assistive Devices List: 12.h Crutch(es) 12.1 Prosthetics	Removed	Del	Based on Round 1 Testing, removed items for no responses	No
	Added to the Assistive Devices List: Reacher/grabber Sock aid Raised toilet seat Glucometer Continuous positive airway pressure (CPAP) Oxygen concentrator	Add	Based on Round 1 Testing, added devices	No
16. Has the PAID caregiver(s) ability, willingness, or availability changed during the past month? 0. No – it was the same (or better). 1. Yes – caregiver(s) had less ability, willingness, or availability	Removed	Del	Redundant	No
17. Has the UNPAID caregiver(s) ability, willingness, or availability changed during the past month? 0. No – it was the same (or better). 1. Yes – caregiver(s) had less ability, willingness or availability.	Removed	Del	Redundat	No

---

Sheet 2: FASI Training

2016 (old version)	2019 (new version)	Type of Change	Reason for Change	Burden Change
Slide 1 Truven Health Analytics logo	Removed logo	Del	Truven no longer involved	No
Slide 2 FASI Project Team	Removed Truven and GW team members no longer involved	Rev	Changed to reflect planned training team	No
Page 57 IADL List 11k. Simple financial management: The ability to complete financial transactions such as counting coins, verifying change for a single item transaction or writing a check.	11k. Simple financial management: The ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.	Rev	Based on Round 1 Testing, added examples for clarity	No
Slide 69 Assistive Device Items	Removed: 12.h Crutch(es) 12.1 Prosthetics Added to the Assistive Devices List: Reacher/grabber Sock aid Raised toilet seat Glucometer Continuous positive airway pressure (CPAP) Oxygen concentrator	Del Add	Based on Round 1 Testing, removed items for no responses and added devices	No
Slide 76 Availability of Paid and Unpaid Assistance	Deleted slide	Del	Removed because Questions 16 and 17 removed for redundancy	No