CMS-370I Individual Observation Worksheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED

OMB NO. 0938-0062

INdIVIdUAL OBSERVATION WORkShEET

Name of Facility

Date

Location/Start

Location/Start

Time/Start

Time/Finish

Surveyor

Client Codes

COLUMN 1 — TIME

Form CMS-3070I (10/95)

COLUMN 2 — OBSERVATION

COLUMN 1 — TIME

COLUMN 2 — OBSERVATION

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-0062. The time required to complete this information collection is estimated to average three hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.
Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact the ICF/IID mailbox at [email protected]. Expiration 02/28/2021

Form CMS-3070I (10/95)