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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Inpatient Rehabilitation Facility-Patient Assessment Instrument
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR Subpart P (To search for a specific CFR, visit the
Code of Federal Regulations.
)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10036
Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Version 1.2 (Proposed DRAFT Effective October 1, 2014) Assessment Quality Indicator Items- Sect 3004 IRF Quality Reporting Program
IRF-PAI-VolMandatChart_v3_508.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10036
IRF-PAI Instrument
508c IRF-PAI 2014.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
Inpatient Rehabilitation Facilities (IRF) Patient Assessment Instrument (IRF-PAI),''
FR Citation:
71 FR 67143
Number of Respondents:
1,161
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 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
359,000
0
359,000
0
0
0
Annual IC Time Burden (Hours)
197,080
0
197,080
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Pressure Ulcer Burden Calculation
PU Burden Calculation. 03.26.13.docx
06/04/2013
Crosswalk - IRF PAI 2014 Admission
CMS Crosswalk- IRF-PAI 2014 Admission v2.doc
06/04/2013
Crosswalk - IRF-PAI 2014 Dischare
CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc
06/04/2013
Influenza Burden Calculation
Pt Influenza Measire. Burden Calculation. 03.21.13.docx
06/05/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.