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

Documents and forms in this information collection
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 CMS-3070G. 06.22.21.pdf	Form and Instruction
CMS-3070H Intermediate Care Facilities for Individuals with Intell CMS-3070H. 06.22..21.pdf	Form and Instruction
CMS-370I Individual Observation Worksheet CMS-3070I. 06.22.21.pdf	Form and Instruction
Change Crosswalk for 3070G. 06.22.21.pdf Crosswalk	IC Document
Change Crosswalk for 3070I. 06.02.21.pdf 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 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

Information Collection Instruments:

table that charts list of 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	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,758

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 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,758	-342	6,100
Annual IC Time Burden (Hours)	17,274	-1,026	18,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.