Information Collection

Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)

IC 7818 under ICR 201003-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-3070G Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	Form
CMS-3070G ICF for Persons with Mental Retardation Survey Report CMS-3070G-I Forms.tif	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 440.150 42 CFR 442.1 42 CFR 440.220 42 CFR 442.10-16 42 CFR 442.30 42 CFR 442.40 42 CFR 442.42 42 CFR 431.52 42 CFR 442.100-119 42 CFR 483.400-480 42 CFR 488.332 42 CFR 488.400 42 CFR 498.3-5 42 CFR 431.151 42 CFR 435.1009

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	CMS-3070G	ICF for Persons with Mental Retardation Survey Report	CMS-3070G-I Forms.tif		No	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,437

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,437	-12,847	19,284
Annual IC Time Burden (Hours)	19,311	27	19,284
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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