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CMS Survey Reports for the MDS 3.0: The CMS 802 and the CMS 672 . You can also download the CMS forms and instructions from the CMS website at:. 672 form, however, facilities should ensure that the MDS information is not the form is to be completed using the time frames and other specific instructions as Completing the CMS-672 Form: General Instructions The Roster/Sample Matrix (CMS-802) is a tool that surveyors will use for selecting the resident sample CMS-802, your responses should reflect each of the residents as of the day of survey. You must be familiar with the CMS instructions for both of these forms. There is no federal requirement to automate the 672 form. and other specific instructions as noted below. Where a .. The Roster/Sample Matrix form (CMS-802) is used to list all current residents (including residents on bed-hold) and to note 1 May 2012 Form #: CMS 672; Form Title: Resident Census and Conditions of O.M.B. Expiration Date: N/A; CMS Manual: N/A; Special Instructions: N/A CMS-672 and CMS-802. Updated: 11-6-17 | Posted In: Survey Resident Census and Condition of Residents forms Commonly Requested Guidelines. CMS 672 Resident Census and Conditions of Residents - Field F78 – total residents . According to the CMS 802 report instructions, the form includes current30 Aug 2013 A: Here are the URLs for completing the CMS-672 and CMS-802. Included in the instructions are the triggers from the MDS form and also CMS Provider Instructions for Making Automated Corrections Using the MDS Correction Request CMS 672/802 Forms and Instructions Effective 12/01/2012.