Functional Assessment Standardized Items (FASI): Round 1

Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)

⚠️ Notice: This information collection may be referencing outdated material.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

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

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	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 %

	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

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.