View Information Collection (IC)

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 440.150 42 CFR 442.1 42 CFR 440.220 42 CFR 442.10-16 42 CFR 442.30 42 CFR 442.40 42 CFR 442.42 42 CFR 431.52 42 CFR 442.100-119 42 CFR 483.400-480 42 CFR 488.332 42 CFR 488.400 42 CFR 498.3-5 42 CFR 431.151 42 CFR 435.1009

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-3070G	ICF for Persons with Mental Retardation Survey Report	CMS-3070G-I Forms.tif		No	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,437	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 %

	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	6,437	0	0	-12,847	0	19,284
Annual IC Time Burden (Hours)	19,311	0	0	27	0	19,284
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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