View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Functional Assessment Standardized Items (FASI): Round 1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FASIAssessorTrainingOct2019508.pdf		No		Printable Only
Form and Instruction	CMS-10243	Consent Form	FASIConsentAssentForms508.pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-10243	Functional Assessment Standardized Items (FASI)	FASI_OMB_09381037_print.pdf		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,570	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	1,570	0	0	0	0	1,570
Annual IC Time Burden (Hours)	785	0	0	0	0	785
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	FASI_Crosswalk.xlsx	12/18/2019
FASI Annotated with Changes	FASI_OMB_09381037_print_with_changes.pdf	12/18/2019

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