ICF/MR Survey Report Form (3070G-I) and Supporting Regulations -- 42 CFR Sections 431, 435, 440, 442, and 483, Subpart I

ICR 199703-0938-003

OMB: 0938-0062

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0062 199703-0938-003
Historical Active 199311-0938-007
HHS/CMS
ICF/MR Survey Report Form (3070G-I) and Supporting Regulations -- 42 CFR Sections 431, 435, 440, 442, and 483, Subpart I
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 04/29/1997
Retrieve Notice of Action (NOA) 03/07/1997
OMB approves the The ICF/MR Survey Report Form, as amended by the April 28 fax, which corrected inaccurate statements of "program changes/burden changes."
  Inventory as of this Action Requested Previously Approved
04/30/2000 04/30/2000
7,200 0 0
21,600 0 0
0 0 0

The survey form and supporting regulations are needed to ensure provider compliance. In order to participate in the Medicaid program as an ICF/MR, providers must meet Federal standards. The survey report form is used to record providers' compliance with the individual standard and report it to the Federal Government.

None
None


No

1
IC Title Form No. Form Name
ICF/MR Survey Report Form (3070G-I) and Supporting Regulations -- 42 CFR Sections 431, 435, 440, 442, and 483, Subpart I 3070G-I

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 7,200 0 0 7,200 0 0
Annual Time Burden (Hours) 21,600 0 0 21,600 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/07/1997


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