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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Fire Safety Survey Report Forms (CMS-2786)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
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
Information Collection Instruments:
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
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:
27,900
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
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
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
Documents for IC
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.