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

Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) and Supporting Regulations at 42CFR 442.30, 483.410, 483.420,...

OMB: 0938-0062

IC ID: 7818

Information Collection (IC) Details

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Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 431.52 42 CFR 431.151 42 CFR 435.1009 42 CFR 440.150 42 CFR 440.220 42 CFR 442.1 42 CFR 442.10-16 42 CFR 442.30 42 CFR 442.40 42 CFR 442.42 42 CFR 442.100-119 42 CFR 483.400-480 42 CFR 488.332 42 CFR 488.400 42 CFR 498.3-5

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report CMS-3070G_508.pdf-rev.4-24.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-3070H Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report CMS-3070H-508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

6,446 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 6,446 0 9 0 6,437 0
Annual IC Time Burden (Hours) 19,338 0 27 0 19,311 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Form CMS.docx 09/11/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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