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

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

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 442.42 42 CFR 442.30 42 CFR 442.40 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-370I Individual Observation Worksheet 8_Rev_CMS3070I PRA disclosure update 06.19.19.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 PRA disclosure update 06.19.19.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report 6_Rev_CMS-3070G_508 pdf PRA disclosure update 06.19.19.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

6,100 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 6,100 0 0 -210 0 6,310
Annual IC Time Burden (Hours) 18,300 0 0 -630 0 18,930
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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