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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:
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
IRF-PAI Voluntary Mandatory Chart 02-20-2014.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10036
IRF-PAI instrument
IRF-PAI_Oct_2014_v4.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 Facility - Patient Assessment Instrument
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 %
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
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
Crosswalk - Admissions
CMS Crosswalk- IRF-PAI 2014 Admission v2.doc
02/28/2014
Crosswalk - Discharge
CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc
02/28/2014
Infulenza Burden
Pt Influenza Measure. Burden Calculation. 03.21.13.docx
02/28/2014
Pressure Ulcer Burden
PU Burden Calculation. 03.26.13.docx
02/28/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.