FASI Annotated with Changes

(Identifier:_________________________)

Functional Assessment Standardized Items (FASI)
Please Complete All Items on Each Page

Section A
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.

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(Identifier:_________________________)

Section B

Functional Abilities and Goals

Self-Care
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
self-care performance was unchanged during the past month, column B should be coded the same as column A. If the
activity was not attempted, code the reason.
Please complete the Self-Care Priorities section at the bottom of this page.
CODING:
Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
06. Independent - Person completes the activity by him/
herself with no assistance from a helper.
05. Setup or cleanup assistance - Helper SETS UP or
CLEANS UP; person completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as person completes activity. Assistance may be
provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Person
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable - Person does not usually do this
activity.
88. Not attempted due to short-term medical condition or
safety concerns.

Performance Level
Enter Codes in Boxes
A
B
Usual
Most
Dependent

6a. Eating: The ability to use suitable utensils to bring
food to the mouth and swallow food once the
meal is presented on a table/tray. Includes
modified food consistency.
6b. Oral hygiene: The ability to use suitable items to
clean teeth. [Dentures (if applicable): The ability
to remove and replace dentures from and to the
mouth, and manage equipment for soaking and
rinsing them.]
6c. Toileting hygiene: The ability to maintain
perineal/feminine hygiene, adjust clothes before
and after using the toilet, commode, bedpan or
urinal. If managing an ostomy, include wiping the
opening but not managing equipment.
6d. Wash upper body: The ability to wash, rinse, and
dry the face, hands, chest, and arms while sitting
in a chair or bed.
6e. Shower/bathe self: The ability to bathe self in
shower or tub, including washing, rinsing, and
drying self. Does not include transferring in/out of
tub/shower.
6f. Upper body dressing: The ability to put on and
remove shirt or pajama top; includes buttoning, if
applicable.
6g. Lower body dressing: The ability to dress and
undress below the waist, including fasteners; does
not include footwear.
6h. Putting on/taking off footwear: The ability to put
on and take off socks and shoes or other footwear
that is appropriate for safe mobility.

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.
1.

2.

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(Identifier:_________________________)

Section B

Functional Abilities and Goals

Mobility (Bed mobility and transfers)
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
transfer/bed mobility performance was unchanged during the past month, column B should be coded the same as column
A. If the activity was not attempted, code the reason.
CODING:
Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
06. Independent - Person completes the activity by him/
herself with no assistance from a helper.
05. Setup or cleanup assistance - Helper SETS UP or
CLEANS UP; person completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as person completes activity. Assistance may be
provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Person
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the
person to complete the activity.

Performance Level
Enter Codes in Boxes
A
B
Usual
Most
Dependent

7a. Roll left and right: The ability to roll from lying on
back to left and right side, and return to lying on
back.
7b. Sit to lying: The ability to move from sitting on
side of bed to lying flat on the bed.
7c. Lying to sitting on side of bed: The ability to
safely move from lying on the back to sitting on
the side of the bed with feet flat on the floor, and
with no back support.
7d. Sit to stand: The ability to safely come to a
standing position from sitting in a chair or on the
side of the bed.
7e. Chair/bed-to-chair transfer: The ability to safely
transfer to and from a bed to a chair (or
wheelchair).
7f. Toilet transfer: The ability to safely get on and off
a toilet or commode.
7g. Car transfer: The ability to transfer in and out of a
car or van on the passenger side. Does not include
the ability to open/close door or fasten seat belt.

If activity was not attempted, code reason:
07. Person refused.
09. Not applicable - Person does not usually do this
activity.
88. Not attempted due to short-term medical condition or
safety concerns.

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(Identifier:_________________________)

Section B

Functional Abilities and Goals

Mobility (Ambulation)
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
ambulation mobility performance was unchanged during the past month, column B should be coded the same as column A.
If the activity was not attempted, code the reason.
CODING:
Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
Performance Level
06. Independent - Person completes the activity by him/
Enter Codes in Boxes
herself with no assistance from a helper.
A
B
05. Setup or cleanup assistance - Helper SETS UP or
Usual
Most
CLEANS UP; person completes activity. Helper assists
Dependent
only prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as person completes activity. Assistance may be
provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Person
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the
person to complete the activity.

If activity was not attempted, code reason:
07. Person refused.
09. Not applicable - Person does not usually do this
activity.
88. Not attempted due to short-term medical condition or
safety concerns.

8. Does the person walk?
0. Yes - Continue to question 8a.
1. No, but walking is indicated in the future - skip
to question 9.
2. No, and walking is not indicated - skip to
question 9.

8a. Walks 10 feet: Once standing, the ability to walk
at least 10 feet in a room, corridor or similar space.
8b. Walks 50 feet with two turns: Once standing, the
ability to walk at least 50 feet and make two turns.
8c. Walks 150 feet: Once standing, the ability to walk
at least 150 feet in a corridor or similar space.
8d. Walks 10 feet on uneven surfaces: The ability to
walk 10 feet on uneven or sloping surfaces, such
as grass or gravel.
8e. 1 step (curb): The ability to step over a curb or up
and down one step.
8f. 4 steps: The ability to go up and down four steps
with or without a rail.
8g. 12 steps: The ability to go up and down 12 steps
with or without a rail.
8h. Walks indoors: from room to room, around
furniture and other obstacles.
8i. Carries something in both hands: While walking
indoors e.g. several dishes, light laundry basket,
tray with food.
8j. Picking up object: The ability to bend/stoop from
a standing position to pick up a small object, such
as a spoon, from the floor.
8k. Walks for 15 minutes: without stopping or resting
(e.g., department store, supermarket.)
8l. Walks across a street: crosses street before light
turns red.

Page 4 of 10

(Identifier:_________________________)

Section B

Functional Abilities and Goals

Mobility (Wheelchair)
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
wheelchair mobility performance was unchanged during the past month, column B should be coded the same as column A.
If the activity was not attempted, code the reason.
Please complete the Mobility Priorities section at the bottom of this page.
CODING:

9. Does the person use a manual wheelchair?
0. No - Skip to question 10.
1. Yes - Continue to question 9a.
Manual Wheelchair

Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
Performance Level
provided.
Enter
Codes in Boxes
Activities may be completed with or without assistive devices.
A

B

Usual
06. Independent - Person completes the activity by him/
Most
Dependent
herself with no assistance from a helper.
05. Setup or cleanup assistance - Helper SETS UP or
9a. Wheels 50 feet with two turns: Once seated in
CLEANS UP; person completes activity. Helper assists
wheelchair/scooter, the ability to wheel at least 50
only prior to or following the activity.
feet and make two turns.
04. Supervision or touching assistance - Helper provides
9b.Wheels 150 feet: Once seated in wheelchair/ scooter,
VERBAL CUES or TOUCHING/STEADYING assistance
the ability to wheel at least 150 feet in a corridor or
as person completes activity. Assistance may be
similar space.
provided throughout the activity or intermittently.
9c. Wheels for 15 minutes: without stopping or resting
03. Partial/moderate assistance - Helper does LESS
(e.g., department store, supermarket.)
THAN HALF the effort. Helper lifts, holds or supports
9d. Wheels across a street: crosses street before light
trunk or limbs, but provides less than half the effort.
turns red.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
10. Does the person use a motorized wheelchair/scooter?
limbs and provides more than half the effort.
0. No - Skip to question 11a.
01. Dependent - Helper does ALL of the effort. Person
1. Yes - Continue to question 10a.
does none of the effort to complete the activity. Or, the
Motorized Wheelchair/Scooter
assistance of 2 or more helpers is required for the
Performance Level
person to complete the activity.
Enter Codes in Boxes
A
B
If activity was not attempted, code reason:
Usual
Most
07. Person refused.
Dependent
09. Not applicable - Person does not usually do this
10a. Wheels 50 feet with two turns: Once seated in
activity.
wheelchair/scooter, the ability to wheel at least 50
88. Not attempted due to short-term medical condition or
feet and make two turns.
safety concerns.
10b. Wheels 150 feet: Once seated in wheelchair/
scooter, the ability to wheel at least 150 feet in a
corridor or similar space.

10c. Wheels for 15 minutes: without stopping or resting
(e.g., department store, supermarket.)
10d. Wheels across a street: crosses street before light
turns red.

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.
1.

2.

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(Identifier:_________________________)

Section B

Functional Abilities and Goals

Instrumental Activities of Daily Living
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
IADL performance was unchanged during the past month, column B should be coded the same as column A. If the activity
was not attempted, code the reason.
CODING:
Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
06. Independent - Person completes the activity by him/
herself with no assistance from a helper.
05. Setup or cleanup assistance - Helper SETS UP or
CLEANS UP; person completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as person completes activity. Assistance may be
provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Person
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable - Person does not usually do this
activity.
88. Not attempted due to short-term medical condition or
safety concerns.

Performance Level
Enter Codes in Boxes
A
B
Usual
Most
Dependent

11a. Makes a light cold meal: The ability to plan and
prepare all aspects of a light cold meal such as a
bowl of cereal and sandwich and cold drink.
11b. Makes a light hot meal: The ability to plan and
prepare all aspects of a light hot meal such as
heating a bowl of soup and reheating a prepared
meal.
11c. Light daily housework: The ability to complete
light daily housework to maintain a safe home
environment such that the person is not at risk
for harm within their home. Examples include
wiping counter tops or doing dishes.
11d. Heavier periodic housework: The ability to
complete heavier periodic housework to
maintain a safe home environment such that
person is not risk for harm within their home.
Examples include doing laundry, vacuuming,
cleaning bathroom.
11e. Light shopping: Once at store, can locate and
select up to five needed goods, take to check
out, and complete purchasing transaction.
11f. Telephone-answering call: The ability to answer
call in person's customary manner and maintain
for 1 minute or longer. Does not include getting
to the phone.
11g. Telephone-placing call: The ability to place call
in person's customary manner and maintain for 1
minute or longer. Does not include getting to the
phone.

Page 6 of 10

(Identifier:_________________________)

Section B

Functional Abilities and Goals

Instrumental Activities of Daily Living (continued)
Form Instructions:
Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's
performance changed during the past month, also code their most dependent performance in Column B. If the person's
IADL performance was unchanged during the past month, column B should be coded the same as column A. If the activity
was not attempted, code the reason.
Please complete the IADL Priorities section at the bottom of the page.
CODING:
Safety and Quality of Performance - If helper assistance
is required because person's performance is unsafe or of
poor quality score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
06. Independent - Person completes the activity by him/
herself with no assistance from a helper.
05. Setup or cleanup assistance - Helper SETS UP or
CLEANS UP; person completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as person completes activity. Assistance may be
provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Person
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable - Person does not usually do this
activity.
88. Not attempted due to short-term medical condition or
safety concerns.

Performance Level
Enter Codes in Boxes
A
B
Usual
Most
Dependent

11h. Medication management-oral medications:
The ability to prepare and take all prescribed oral
medications reliably and safely, including
administration of the correct dosage at the
appropriate times/intervals.
11i. Medication management-inhalant/mist
medications: The ability to prepare and take all
prescribed inhalant/mist medications reliably and
safely, including administration of the correct
dosage at the appropriate times/intervals.
11j. Medication management-injectable
medications: The ability to prepare and take all
prescribed injectable medications reliably and
safely, including administration of the correct
dosage at the appropriate times/intervals.
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.
11l. Complex financial management: The ability to
complete financial decision-making such as
budget and remembering to pay bills.

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.
1.

2.

Page 7 of 10

(Identifier:_________________________)

Section C

Assistive Devices

Assistive Devices for Everyday Activities
Form Instructions:
Identify the person's need for and availability of each assistive device. If no assistive device is needed to complete self-care,
mobility, and instrumental activities of daily living, check "Not Applicable" box. If device is not used, code reason.
CODING:

Enter Codes in
Boxes

Code the person's usual need for, and availability of,
assistive devices to complete self-care, mobility, or
instrumental activities of daily living.

12a. Manual wheelchair

02. Assistive device needed and available - Person needs
this device to complete daily activities and has the
device in the home.

12c. Specialized seating pad (e.g. air-filled, gel, shaped foam)

01. Assistive device needed but current device unsuitable
- Device is in home but no longer meets person's needs.
00. Assistive device needed but not available - Person
needs the device but it is not available in the home.

12b. Motorized wheelchair or scooter

12d. Mechanical lift
12e. Walker
12f. Walker with seat
12g. Cane
12h. Reacher/Grabber

If device is not used, code reason:
07. Person refused - Person chooses not to use needed
device.
09. Not applicable - Person does not need this device.

12i. Sock aid
12j. Orthotics/Brace
12k. Bed rail
12l. Electronic bed
12m. Grab bars
12n. Transfer board
12o. Shower/commode chair
12p. Walk/wheel-in shower
12q. Glasses or contact lenses
12r. Hearing aid
12s. Communication device
12t. Stair rails
12u. Lift chair
12v. Ramps
12w. Raised toilet seat
12x. Glucometer
12y. CPAP
12z. Oxygen concentrator
Other:
I have indicated all the devices needed.
Not Applicable - No assistive device needed in past month
Page 8 of 10

(Identifier:_________________________)

Section D

Living Arrangements, Caregiver Assistance and Availability

Living Arrangements
13. Identify the person's usual living arrangement during the past 3 days and the
past month.
CODING:
05. Person lives alone - no other residents in the home.
04. Person lives with others in the home - for example, family, friends, or paid
caregiver.
03. Person lives in congregate home - for example, assisted living, or residential care
home.
02. Person does not have a permanent home or is homeless.
01. Person was in a medical facility.

A
Past 3 Days

B
Past Month

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.
1.

2.

Availability of Assistance
14. Does the person have assistance in their home?
0. No - Do not code availability of assistance - skip to question 15a.
1. Yes - Continue to question 14a.
14a. Code the level of assistance in the person's home (both paid and unpaid)
during the past month.
CODING:
05. No assistance received
04. Occasional/short term assistance
03. Regular night time
02. Regular daytime
01. Around the clock

A
Paid

B
Unpaid

Page 9 of 10

(Identifier:_________________________)

Section D

Living Arrangements, Caregiver Assistance and Availability

Availability of Paid and Unpaid Assistance
Form Instructions:
Code the Paid caregiver's usual ability and willingness to provide assistance with each activity during the past 3 days in
Column A and the Unpaid caregiver's usual ability and willingness to provide assistance with each activity during the past 3
days in Column B. If the activity was not attempted, code as not applicable (09).
Please complete the Living Arrangement and Caregiving Priorities section at the bottom of this page.
CODING:
Enter Codes in Boxes
Code safety and quality of BOTH paid and unpaid caregiver
A
B
assistance and their willingness to provide assistance with
Paid
Unpaid
each of the following activities.
05. Assistance not needed - No assistance needed.
04. Caregiver(s) currently provide assistance - Person's
usual caregiver(s) willing and able to provide needed
assistance.
03. Caregiver(s) need training/supportive services to
provide assistance - Caregiver(s) available and need
assistance to provide support.
02. Unclear if caregiver(s) will provide assistance Caregiver(s) available in the home but it is not clear if
caregiver(s) will provide needed assistance.
01. Assistance needed but no caregiver(s) available Person needs assistance but no caregiver(s) available in
the home.
00. Assistance needed but person declines assistance Person needs caregiving but declines this assistance.
09. Not applicable - Person does not do this activity.

15a. Self-care assistance (for example, bathing,
dressing, toileting, or eating/feeding).
15b. Mobility assistance (for example, bed mobility,
transfers, ambulating, or wheeling).
15c. IADL assistance (for example, making meals,
housekeeping, telephone, shopping, or
finances).
15d. Medication administration (for example, oral,
inhaled, or injectable medications).
15e. Medical procedures/treatments (for example,
changing wound dressing, or home exercise
program).
15f. Management of equipment (for example, oxygen,
IV/infusion equipment, enteral/parenteral
nutrition, or ventilator therapy equipment and
supplies).
15g. Supervision (for example, due to safety
concerns).
15h. Advocacy or facilitation of person's participation
in appropriate medical care (for example,
transportation to or from appointments).

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.
1.

2.

Page 10 of 10