Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 202210-0938-004 · OMB 0938-0842.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0842 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment Instrument	Form and Instruction
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf	Instruction
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf	Instruction
CMS-10036 IRF- PAI version 4.1 IRF-PAI-Version-4.1-Effective-10-01-23-Final.pdf	Form and Instruction
CMS-10036 IRF- PAI version 4.1 IRF-PAI-Version-4.1-Effective-10-01-23-Final.pdf	Form and Instruction
Crosswalk_IRF-PAI 4.0 to 4.1.docx Crosswalk	IC Document
Crosswalk_IRF-PAI 4.0 to 4.1.docx Crosswalk	IC Document

IC Title:

Inpatient Rehabilitation Facility - Patient Assessment Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10036	IRF- PAI version 4.1	IRF-PAI-Version-4.1-Effective-10-01-23-Final.pdf		Yes	Yes	Fillable Fileable
Instruction			Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Inpatient Rehabilitation Facility - Patient Assessment Instrument

FR Citation: 71 FR 67143

Number of Respondents: 1,115

Number of Respondents for Small Entity: 194

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	672,345	260,723	411,622
Annual IC Time Burden (Hours)	1,187,475	460,277	727,198
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk_IRF-PAI 4.0 to 4.1.docx	10/17/2022

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