ICF/IID Survey Report Form (CMS-3070G-I) and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-3070G Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) Form and Instruction	Modified
Form CMS.docx Supplementary Document	2013-09-11
CMS 3070_Final Supporting Statement - Part A_2016 .doc Supporting Statement A	2017-01-27

IC Document Collections

IC ID	Document Title	Status
7818	Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0062	ICR Reference No: 201701-0938-009
Status: Historical Active	Previous ICR Reference No: 201309-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: 20527
Title: ICF/IID Survey Report Form (CMS-3070G-I) and Supporting Regulations
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/21/2017
	Date Received in OIRA: 01/27/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	06/30/2017
Responses	6,310	0	6,446
Time Burden (Hours)	18,930	0	19,338
Cost Burden (Dollars)	0	0	0

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Abstract: This survey form is necessary to ensure ICF/IID provider and client characteristics are available and updated annually for the Federal Government's Automated Survey Processing Environment Suite (ASPEN). The surveyor is required to complete the survey foram at the time of the annual recertification or intial certification survey conducted by the State Survey agency. The team leader for the State Survey team must review and approve the completed form before the completion of the survey. The State Medicaid survey agency is responsible for transferring the 3070H information into ASPEN.

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Authorizing Statute(s): Statute at Large: 19 Stat. 1905 Name of Statute: null
   Statute at Large: 19 Stat. 1902 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 76945	11/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 4887	01/17/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	CMS-3070G, CMS-3070H, CMS-370I	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report ,   Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report ,   Individual Observation Worksheet

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ICR Summary of Burden

	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	6,310	6,446	0	0	-136	0
Annual Time Burden (Hours)	18,930	19,338	0	0	-408	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden changed due to a decrease in facilities when individuals were moved from larger institutions to smaller community settings.

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Annual Cost to Federal Government: $605,760

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 01/27/2017

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