Information Collection

Functional Assessment Standardized Items (FASI): Round 1

IC 222991 under ICR 201912-0938-009 · OMB 0938-1037.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1037 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FASIAssessorTrainingOct2019508.pdf	Instruction
CMS-10243 Consent Form FASIConsentAssentForms508.pdf	Form and Instruction
CMS-10243 Functional Assessment Standardized Items (FASI) FASI_OMB_09381037_print.pdf	Form and Instruction
FASI_Crosswalk.xlsx Crosswalk	IC Document
FASI_OMB_09381037_print_with_changes.pdf FASI Annotated with Changes	IC Document

IC Title:

Functional Assessment Standardized Items (FASI): Round 1

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FASIAssessorTrainingOct2019508.pdf	No		Printable Only
Form and Instruction	CMS-10243	Consent Form	FASIConsentAssentForms508.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10243	Functional Assessment Standardized Items (FASI)	FASI_OMB_09381037_print.pdf	No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,570

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,570	1,570
Annual IC Time Burden (Hours)	785	785
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	FASI_Crosswalk.xlsx	12/18/2019
FASI Annotated with Changes	FASI_OMB_09381037_print_with_changes.pdf	12/18/2019

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