Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) and Supporting Regulations at 42CFR 442.30, 483.410, 483.420,...

Forms and Documents

Document Name	Status
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	Modified
Form CMS.docx Supplementary Document	2013-09-11
CMS-3070 Supporting Statement ICFIID FINAL 3-12-13.doc Supporting Statement A	2013-09-11

IC Document Collections

IC ID	Document Title	Status
7818	Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0062	ICR Reference No: 201309-0938-012
Status: Historical Active	Previous ICR Reference No: 201003-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 20527
Title: Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) and Supporting Regulations at 42CFR 442.30, 483.410, 483.420,...
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/2014
	Date Received in OIRA: 09/13/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	6,446	0	0
Time Burden (Hours)	19,338	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): Statute at Large: 19 Stat. 1905 Name of Statute: null
   Statute at Large: 19 Stat. 1902 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 34387	06/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 50057	08/16/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I)	CMS-3070G, CMS-3070H	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report ,   Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,446	0	0	9	0	6,437
Annual Time Burden (Hours)	19,338	0	0	27	0	19,311
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden change is due to the following: The response time of three hours remains unchanged from the previous submission 3 years ago. There are 6,446 (as of January 2013) facilities surveyed annually X 3 hours to complete the forms, totaling 19,338 burden hours. The burden changed due to an increase of nine facilities which were opened when individuals were moved from larger institutions to smaller community setting

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Annual Cost to Federal Government: $618,816

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/13/2013

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