Information Collection

Functional Assessment Standardized Items (FASI): Round 1

IC 222991 under ICR 202304-0938-030 · OMB 0938-1037.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FASIAssessorTrainingOct2019508.pdf	Instruction
FASIAssessorTrainingOct2019508.pdf	Instruction
CMS-10243 Consent Form ConsentAssentForms508 (2023 version 1).pdf	Form and Instruction
CMS-10243 Consent Form ConsentAssentForms508 (2023 version 1).pdf	Form and Instruction
CMS-10243 Functional Assessment Standardized Items (FASI) FASI_OMB_09381037_print.pdf	Form and Instruction
CMS-10243 Functional Assessment Standardized Items (FASI) FASI_OMB_09381037_print.pdf	Form and Instruction
Crosswalk - Consent Form.xlsx Crosswalk of Changes: Consent Form	IC Document
Crosswalk - Consent Form.xlsx Crosswalk of Changes: Consent Form	IC Document

IC Title:

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	ConsentAssentForms508 (2023 version 1).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: Post-Acute Care Payment Reform/Continuity of Assessment Records and Report Evaluation Demonstration and Evaluation (PACâ CARE)

FR Citation: 83 FR 6591

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 of Changes: Consent Form	Crosswalk - Consent Form.xlsx	04/28/2023

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