Information Collection

Medicaid -- Intermediate Care Facility For The Mentally Retarded Or Persons With Related Conditions Survey Report Form

IC 112715 under ICR 198612-0938-003 · OMB 0938-0062.

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Documents and Forms

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IC Title:

MEDICAID -- INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED OR PERSONS WITH RELATED CONDITIONS SURVEY REPORT FORM

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-3070B				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,251

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,251	3,251
Annual IC Time Burden (Hours)	9,753	9,753
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.