How to use the Forms Library
The library groups official CMS forms and tools by common workflows. Before relying on a form for survey evidence, verify the governing source and capture it as a citation (see footnotes below).
Related glossary: CMS K-tag, Corrective action, Survey readiness, Evidence trail, Emergency preparedness
Form category
Fire and Life Safety Survey Tools
CMS survey reports and evaluation worksheets used for health care, ambulatory surgical center, and ESRD life-safety reviews.
Fire Safety Survey Report - Health Care
The 50-page CMS report for surveying health care occupancies under the 2012 Life Safety Code and Health Care Facilities Code, organized by K-tag.
- Best used for
- Hospitals, skilled nursing facilities, qualifying ICF/IID health care occupancies, and inpatient hospice facilities.
- Revision or status
- 07/2018
Use note: Blank survey report; CMS forms are completed and retained as part of the survey record.
Fire Safety Evaluation System - Health Care
CMS worksheets for evaluating alternative life-safety approaches for health care facilities using NFPA 101A.
- Best used for
- Qualified evaluation of fire/smoke zones when the Fire Safety Evaluation System is applicable.
- Revision or status
- 02/2026
Use note: Use only with the applicable survey and authority process; this is not a self-certification tool.
Fire Safety Survey Report - ASC and ESRD
The CMS 2012 Life Safety Code survey report for ambulatory surgical centers and end-stage renal disease facilities.
- Best used for
- ASC and ESRD facilities; use this occupancy-specific report instead of CMS-2786R.
- Revision or status
- 07/2018
Form category
Deficiencies and Corrective Action
Official forms supporting deficiency documentation, plans of correction, and post-certification revisit records.
Statement of Deficiencies and Plan of Correction
The official form for documenting survey deficiencies and the provider or supplier plan of correction. This local copy retains its interactive PDF fields.
- Best used for
- Cross-referencing each cited deficiency to corrective action and an anticipated completion date.
- Revision or status
- 03/18/2022; displayed OMB approval expired 03/31/2025
Use note: Verify the current CMS version and submission instructions before use because this copy displays an expired OMB approval date.
Post-Certification Revisit Report
The CMS report used by a qualified surveyor to identify previously reported deficiencies that were corrected and record completion dates.
- Best used for
- State agency or CMS follow-up documentation after a CMS-2567 survey report.
- Revision or status
- 09/1992; electronic form 11/2006
Use note: Surveyor-facing report; facilities should not treat it as a substitute for accepted correction evidence.
Form category
Emergency Preparedness Planning
Official CMS collections of voluntary templates, checklists, and provider guidance for all-hazards planning and exercises.
CMS Emergency Preparedness Templates and Checklists
CMS collection that includes its emergency preparedness acronym glossary and a voluntary health care provider after-action report and improvement-plan template.
- Best used for
- Emergency exercise or incident follow-up, improvement planning, and shared emergency-preparedness terminology.
- Revision or status
- CMS page reviewed 12/30/2024
Use note: CMS notes that some materials may predate the Emergency Preparedness Final Rule and do not guarantee compliance.
CMS Health Care Provider Emergency Guidance
Current CMS provider guidance and recommended tools covering all-hazards risk assessment, policies, communication, and training and testing.
- Best used for
- Locating provider-specific emergency planning resources and frequently cited emergency-preparedness deficiencies.
- Revision or status
- CMS page reviewed 03/05/2026
Form best practices and evidence tracking
Establish an evidence trail by pairing each completed form with: (1) the governing CMS citation (footnote), (2) a responsible owner, (3) completion date, and (4) a verification record.
Official sources and footnotes
- Centers for Medicare & Medicaid Services (CMS) — official forms and survey guidance.
- CMS regulations and guidance — program interpretive guidance and survey procedures.
- The Joint Commission — accreditation references and resources.
- OSHA — workplace safety and related documentation.
Cite the governing footnote when you attach a completed form to survey evidence.
Need help organizing survey evidence?
Use the forms as part of a controlled evidence trail that connects each finding to its governing source, responsible owner, corrective action, completion date, and verification record.
Discuss survey-readiness support