Draft Assessment Tools Submitted for Public Comment

 On this page you can find prototypes of the assessment tools submitted for public comment under the Paperwork Reduction Act of 1995.  There are three sets of assessment tools, each with admission and discharge variations.  One set is intended for patients in institutional settings (e.g., nursing facilities).  The other two sets are intended for patients in community-based settings; these include a section intended for patient self-report.  One set is entirely in English.  The other set has the patient-reported items in Spanish, but the remaining items in English.

To obtain a copy of the Paperwork Reduction Act materials, click here.  You will be directed to a page on the Web site of the Centers for Medicare & Medicaid Services. That page contains a link to a ZIP file containing the Paperwork Reduction Act Materials.

To obtain a PDF copy of the Federal Register Notice for this data collection, please click here.

The DOTPA data collection is summarized in the first column on Page 52237.

Please note that the deadline for comments is December 8, 2009.  When commenting to CMS on the DOTPA data collection, please reference the CMS Form Number (CMS-10298).

You may submit your comments electronically to http://www.regulations.gov. Follow the instructions for "Comment or Submission" or "More Search Options" to find the information collection document(s) accepting comments.

You may mail written comments to the following address:
CMS
Office of Strategic Operations and Regulatory Affairs Division of Regulations Development
Attention: CMS-10298
Room C4–26–05
7500 Security Boulevard
Baltimore, MD 21244–1850.

 

Assessment Tools for Patients in Institutional Settings:

Admission          Discharge

 

 Assessment Tools for Patients in Community-Based Settings (English Language Patient Self-Report):

Admission          Discharge