View Information Collection (IC)

View Information Collection (IC)

Fire Safety Survey Report Forms (CMS-2786)
 
No Modified
 
Mandatory
 
42 CFR 403.744 42 CFR 418.100 42 CFR 485.623 42 CFR 482.41 42 CFR 460.72 42 CFR 483.70 42 CFR 483.470 42 CFR 416.44

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form Fire & Safety Survey Report CMS-2786R CMS-2786R.pdf No No Paper Only
Form CMS-2786S Fire & Safety Survey Report CMS-2786S.pdf No No Paper Only
Form CMS-2786 M Fire Safety Survey Report CMS-2786M.pdf No No Paper Only
Form CMS-2786T FSES Worksheet CMS-2786T.pdf No No Paper Only
Form CMS-2786V` FSES-ICFs/MR-Small Facilities CMS-2786V.pdf No No Paper Only
Form CMS-2786W FSES - ICFs/MR - Larger Facilities CMS-2786W.pdf No No Paper Only
Form CMS-2786X FSES - ICFs/MR Worksheet for Rating Residents CMS-2786X.pdf No No Paper Only
Form CMS-2786Y FSES - Part III Chapter 7-101A - Board Care CMS-2786Y.pdf No No Paper Only
Form and Instruction CMS-2786U Fire Safety Survey Report - ASC & ESRD Medicare CMS-2786U revised 10-2008.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

27,900 0
   
State, Local, and Tribal Governments
 
   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 27,900 0 0 0 0 27,900
Annual IC Time Burden (Hours) 2,325 0 0 0 0 2,325
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Brief description of changes to 2786U form Brief description of changes to 2786U form.doc 02/25/2009
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.