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
Form CMS-3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	Form and Instruction
Form CMS-3070H Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	Form and Instruction
Form CMS-370I Individual Observation Worksheet 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-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-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
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 3070G. 06.22.21.pdf Crosswalk	IC Document
Change Crosswalk for 3070I. 06.02.21.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 442.40 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 440.220 42 CFR 440.150 42 CFR 442.1 42 CFR 442.10-16 42 CFR 442.42 42 CFR 442.30 42 CFR 488.400 42 CFR 498.3-5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-3070G	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-3070H	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-370I	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
	Approved	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		11/02/2021
Crosswalk		11/02/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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