OMB
.report
Search
Functional Assessment Standardized Items (FASI): Round 1
Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)
OMB: 0938-1037
IC ID: 222991
OMB.report
HHS/CMS
OMB 0938-1037
ICR 201912-0938-009
IC 222991
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1037 can be found here:
2023-04-28 - Revision of a currently approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,570
0
0
0
0
1,570
Annual IC Time Burden (Hours)
785
0
0
0
0
785
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.