Facility details
Facility name, facility address, provider number and total beds.
CMS-801
Offsite Survey Prep Worksheet
- Agency
- CMS
- Revision
- 07/95
- Fillable fields
- 13
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-801: Offsite Survey Preparation Worksheet
Form CMS-801 is the Offsite Survey Preparation Worksheet from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The CMS page lists it as the Offsite Survey Prep Worksheet. It is a single page for preparing a survey of a facility.
The worksheet asks for the facility's name, address, provider number and total beds, the ombudsman's name or number and contact date, the offsite review date and the survey begin date. A large box is for potential facility areas of concern, potential residents to be reviewed during the survey and any current complaints to be investigated onsite. The last section lists surveyors and their discipline, with the team coordinator first.
The form is dated 07/95 and the CMS page lists its OMB number as exempt. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-801
Ombudsman and dates
Ombudsman name or number, ombudsman contact date, offsite review date and survey begin date.
Areas of concern, residents and complaints
A large box to list potential facility areas of concern, any potential residents to be reviewed during the survey and any current complaints to be investigated onsite.
Surveyors and discipline
Lines to list each surveyor and their discipline, with the team coordinator first.
How to fill out Form CMS-801
- 1
Enter the facility details
Fill in the facility name, address, provider number and total beds.
- 2
Record the ombudsman contact and dates
Enter the ombudsman's name or number, the contact date, the offsite review date and the survey begin date.
- 3
List concerns, residents and complaints
In the large box, list potential areas of concern, potential residents to review and current complaints to investigate onsite.
- 4
List the surveyors
Write each surveyor and their discipline, starting with the team coordinator.
Why fill Form CMS-801 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
What the form and the CMS page say
Where it goes
The form prints no mailing address and no filing instructions. The CMS page lists its special instructions as N/A.
OMB status
The CMS page lists the OMB number as exempt. The form prints no OMB number or time estimate.
Edition
The form is printed as Form CMS-801 (07/95), and the CMS page lists a revision date of 1995-07-01.
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CMS-2567
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22 fields, 5 pages
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET
12 fields, 2 pages
Who uses Form CMS-801?
The form does not say who fills it in. Its fields are for planning a facility survey.
Official sources and the blank
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Questions about Form CMS-801
What is Form CMS-801?
It is the Offsite Survey Preparation Worksheet, a one-page CMS form for preparing a facility survey. The CMS page lists it as the Offsite Survey Prep Worksheet.
What facility information does Form CMS-801 ask for?
The facility name, address, provider number and total beds.
What goes in the large box on Form CMS-801?
The form says to list potential facility areas of concern, any potential residents to be reviewed during the survey and any current complaints to be investigated onsite.
How are surveyors listed?
The form asks for surveyors and their discipline, and says to list the team coordinator first.
Does Form CMS-801 have instructions?
The form prints only the short directions on the page, and the CMS page lists its special instructions as N/A.