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

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

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Functional Assessment Standardized Items (FASI): Round 1
 
No Modified
 
Voluntary
 

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 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

Health Health Care Services

Post-Acute Care Payment Reform/Continuity of Assessment Records and Report Evaluation Demonstration and Evaluation (PAC– CARE)  83 FR 6591

1,570 0
   
Individuals or Households
 
   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

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.
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