Information Collection

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

IC 112720 under ICR 199311-0938-007 · OMB 0938-0062.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0062 can be found here:

Documents and Forms

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Information Collection (IC) Details

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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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA 3070G-I				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,701	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,701	383	6,318
Annual IC Time Burden (Hours)	20,103	1,149	18,954
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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