Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 202408-0938-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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 4.2 IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx	Form and Instruction
CMS-10036 IRF- PAI version 4.2 IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx	Form and Instruction
CMS-10036 IRF- PAI version 4.3 IRF-PAI-Version-4.3-Effective-10-01-26.docx	Form and Instruction
CMS-10036 IRF- PAI version 4.3 IRF-PAI-Version-4.3-Effective-10-01-26.docx	Form and Instruction
Crosswalk-IRF-PAI 4.2 to 4.3.docx Crosswalk	IC Document
Crosswalk-IRF-PAI 4.2 to 4.3.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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10036	IRF- PAI version 4.2	IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx	Yes	Yes	Fillable Fileable
Instruction			Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10036	IRF- PAI version 4.3	IRF-PAI-Version-4.3-Effective-10-01-26.docx	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: 1,160

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	571,151	-228,297	799,448
Annual IC Time Burden (Hours)	1,194,814	6,004	1,188,810
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk-IRF-PAI 4.2 to 4.3.docx	08/14/2024

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