Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 202505-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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 4.4 IRF-PAI-Version-4.4.docx Form and Instruction
CMS-10036 IRF- PAI version 4.4 IRF-PAI-Version-4.4.docx Form and Instruction
IRF-PAI-Version-4.4_redlined.pdf IRA-PAI Track Change version IC Document
IRF-PAI-Version-4.4_redlined.pdf IRA-PAI Track Change version IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

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 4.4	IRF-PAI-Version-4.4.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: 1,166	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	622,300	51,149	571,151
Annual IC Time Burden (Hours)	1,179,256	-15,558	1,194,814
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
IRA-PAI Track Change version	IRF-PAI-Version-4.4_redlined.pdf	05/07/2025

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