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 201701-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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 and Instruction
CMS-3070G Intermediate Care Facilities for Individuals with Intell 6_Rev_CMS-3070G_508 pdf.pdf Form and Instruction
CMS-3070H Intermediate Care Facilities for Individuals with Intell 7_Rev_CMS-3070H-508.pdf Form and Instruction
CMS-370I Individual Observation Worksheet 8_Rev_CMS3070I.pdf Form and Instruction
Form CMS.docx Crosswalk IC Document

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 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 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 488.400 42 CFR 498.3-5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-3070G	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report	6_Rev_CMS-3070G_508 pdf.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-3070H	Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report	7_Rev_CMS-3070H-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-370I	Individual Observation Worksheet	8_Rev_CMS3070I.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,310	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,310	-136	6,446
Annual IC Time Burden (Hours)	18,930	-408	19,338
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.