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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 412 Subpart P
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10036
IRF PAI Instrument
CMS-10036.Draft IRF-PAI Instrument.pdf
Yes
Yes
Fillable Fileable
Instruction
CMS-10036.IRF-PAI pressure ulcer instructions for PRA.docx
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
: Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) System of Records, System No. 09-70-1518
FR Citation:
66 FR 56681
Number of Respondents:
1,146
Number of Respondents for Small Entity:
157
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
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
424,020
83,130
0
0
0
340,890
Annual IC Time Burden (Hours)
360,417
70,660
0
0
0
289,757
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-10036_IRF-PAI_Revisions Crosswalk
CMS-10036_IRF-PAI_Revisions Crosswalk.docx
06/01/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.