Form 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

PRA Disclosure Statement: 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 (Expires
2/28/2021). This information collection is mandatory for states to complete as authorized by Title XIX of the Social Security Act, Section 1905(d). To determine compliance with the requirements, section 1902(a)(33)(B) of the Social Security Act requires the State to utilize the same
agency used by the Secretary under Section 1864 of the Act to determine whether institutions meet the requirements for participating in the program. The information collection records data relative to facility characteristics, including a description of the client population served and
essential characteristics of the survey conducted in order to determine compliance with discreet requirements and to report to the Federal government. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. 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, and 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].

Form CMS-3070I (10/95)