Form CMS-807: Surveyor Notes Worksheet

Form CMS-807 is the Surveyor Notes Worksheet from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The form prints Form CMS-807 (03/2024) on each page, and the CMS forms page lists its revision date as 2024-03-01 and its OMB number as exempt.

The first page asks for the facility name, surveyor name, surveyor number, provider number and discipline, and for observation dates from and to in mm/dd/yyyy format. Below those fields are two columns, TAG/CONCERNS and DOCUMENTATION. The second page repeats the same two columns for more notes.

The form prints no instructions and does not say where it goes. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-807: Surveyor Notes Worksheet, as printed by CMS

What's on Form CMS-807

Facility and provider

Facility Name and Provider Number.

Surveyor

Surveyor Name, Surveyor Number and Discipline.

Observation dates

From and To dates, each in mm/dd/yyyy format.

TAG/CONCERNS and DOCUMENTATION

Two note columns on page 1. Page 2 repeats the same two columns with no header fields.

Two pages, with the header fields on page 1 only.

How to fill out Form CMS-807

1
Identify the facility
Enter the facility name and provider number.
2
Identify the surveyor
Enter the surveyor name, surveyor number and discipline.
3
Enter observation dates
Add the From and To dates of the observation in mm/dd/yyyy format.
4
Record tags and documentation
Write each tag or concern in the left column and its documentation in the right column. Page 2 has more room in the same two columns.

The form prints no instructions. These steps follow its fields in order.

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What the form says

Instructions and filing

The form prints no instructions, no mailing address and no deadline.

OMB status

The CMS page lists the O.M.B. number as EXEMPT. The form itself prints no OMB number.

Revision

Each page prints Form CMS-807 (03/2024). The CMS page lists a revision date of 2024-03-01.

Who uses Form CMS-807?

Surveyors
The form is titled Surveyor Notes Worksheet and asks for the surveyor's name and surveyor number.
Surveyors by discipline
The form has a Discipline field next to the provider number, on the same page as the surveyor's name and number.
The facility named
The facility name and provider number identify the facility the worksheet's notes are about.

The form gives no instructions. Its fields name the people and facility below.

Official sources and the blank

Official CMS form page
The agency’s own page for Form CMS-807.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form CMS-807

What is Form CMS-807?

It is the Surveyor Notes Worksheet from CMS, a two-page worksheet with a facility and surveyor header and TAG/CONCERNS and DOCUMENTATION columns.

What does Form CMS-807 ask for?

Facility name, surveyor name and number, provider number, discipline, and observation dates from and to in mm/dd/yyyy format, then notes by tag or concern with documentation.

Does Form CMS-807 have instructions or a filing address?

No. The form prints no instructions and does not say where it goes.

Does Form CMS-807 have an OMB number?

The CMS page lists its O.M.B. number as EXEMPT, and the form prints none.

Form CMS-807: Surveyor Notes Worksheet