Information Collection

Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)

IC 8848 under ICR 202303-0938-006 · OMB 0938-0986.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-437 A Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)	Form and Instruction
CMS-437 A REHABILITATION UNIT CRITERIA WORK SHEET CMS-437A.11.23.22.pdf	Form and Instruction
CMS-437 A REHABILITATION UNIT CRITERIA WORK SHEET CMS-437A.11.23.22.pdf	Form and Instruction
CMS-437B REHABILITATION HOSPITAL CRITERIA WORK SHEET CMS437B. 11.21.22.pdf	Form and Instruction
CMS-437B REHABILITATION HOSPITAL CRITERIA WORK SHEET CMS437B. 11.21.22.pdf	Form and Instruction
Change Crosswalk for CMS-437a form. 04.18.23.docx crosswalk	IC Document
Change Crosswalk for CMS-437a form. 04.18.23.docx crosswalk	IC Document
Change Crosswalk for CMS-437b form. 04.18.23.docx crosswalk	IC Document
Change Crosswalk for CMS-437b form. 04.18.23.docx crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-437 A	REHABILITATION UNIT CRITERIA WORK SHEET	CMS-437A.11.23.22.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-437B	REHABILITATION HOSPITAL CRITERIA WORK SHEET	CMS437B. 11.21.22.pdf		Yes	Yes	Fillable Fileable

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: 497

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	497	-629	1,126
Annual IC Time Burden (Hours)	497	-629	1,126
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
crosswalk	Change Crosswalk for CMS-437a form. 04.18.23.docx	04/19/2023
crosswalk	Change Crosswalk for CMS-437b form. 04.18.23.docx	04/19/2023

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