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Federal forms, ICRs, and supporting documents

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 202111-0938-002 · OMB 0938-0062.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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 440.220 42 CFR 440.150 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-3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report CMS-3070G. 06.22.21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-3070H Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report CMS-3070H. 06.22..21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-370I Individual Observation Worksheet CMS-3070I. 06.22.21.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

5,758 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested 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 5,758 0 0 -342 0 6,100
Annual IC Time Burden (Hours) 17,274 0 0 -1,026 0 18,300
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Change Crosswalk for 3070G. 06.22.21.pdf 11/02/2021
Crosswalk Change Crosswalk for 3070I. 06.02.21.pdf 11/02/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.