OMB control number

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

OMB 0938-0062 · HHS/CMS.

OMB 0938-0062

This survey form is necessary to ensure ICF/IID provider and client characteristics are available and updated annually for the Federal Government's Automated Survey Processing Environment Suite (ASPEN). The surveyor is required to complete the survey foram at the time of the annual recertification or intial certification survey conducted by the State Survey agency. The team leader for the State Survey team must review and approve the completed form before the completion of the survey. The State Medicaid survey agency is responsible for transferring the 3070H information into ASPEN.

The latest form for ICF/IID Survey Report Form (CMS-3070G-I) and Supporting Regulations expires 2022-06-30 and is listed under ICR 201903-0938-013.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
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
Supporting Statement A for CMS-3070G-I. 10.25.21.docx	Supporting Statement A
Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202111-0938-002	Revision of a currently approved collection	2021-11-03	Approved without change
201903-0938-013	Extension without change of a currently approved collection	2019-04-02	Approved with change
201701-0938-009	Extension without change of a currently approved collection	2017-01-27	Approved with change
201309-0938-012	Reinstatement with change of a previously approved collection	2013-09-13	Approved without change
201003-0938-001	Extension without change of a currently approved collection	2010-03-17	Approved without change
200701-0938-009	Extension without change of a currently approved collection	2007-01-12	Approved without change
200311-0938-007	Extension without change of a currently approved collection	2003-11-25	Approved without change
200009-0938-004	Reinstatement with change of a previously approved collection	2000-09-13	Approved without change
199703-0938-003	Reinstatement with change of a previously approved collection	1997-03-07	Approved without change
199311-0938-007	Revision of a currently approved collection	1993-11-22	Approved without change
199208-0938-006	Reinstatement with change of a previously approved collection	1992-08-17	Approved without change
198912-0938-006	Reinstatement with change of a previously approved collection	1989-12-11	Approved without change
198808-0938-001	Revision of a currently approved collection	1988-08-24	Approved without change
198802-0938-006	Revision of a currently approved collection	1988-02-23	Approved without change
198612-0938-003	Reinstatement with change of a previously approved collection	1986-12-15	Approved without change
198609-0938-005	No material or nonsubstantive change to a currently approved collection	1986-09-12	Approved with change
198601-0938-008	No material or nonsubstantive change to a currently approved collection	1986-01-10	Approved with change
198409-0938-012	Reinstatement with change of a previously approved collection	1984-09-28	Approved without change
198301-0938-007	Reinstatement without change of a previously approved collection	1983-01-17	Disapproved
198204-0938-002	Reinstatement with change of a previously approved collection	1982-04-02	Approved without change
198112-0938-008	Revision of a currently approved collection	1981-12-04	Approved without change
198107-0938-014	No material or nonsubstantive change to a currently approved collection	1981-07-28	Approved with change
198101-0938-006	Reinstatement with change of a previously approved collection	1981-01-08	Approved without change
197905-0938-004	Revision of a currently approved collection	1979-05-24	Approved without change
197710-0938-003	Revision of a currently approved collection	1977-10-03	Approved without change
197709-0938-002	Revision of a currently approved collection	1977-09-13	Not subject to PRA and continue
197410-0938-001	New collection (Request for a new OMB Control Number)	1974-10-02	Approved without change