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

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
Supporting Statement A for CMS-3070G-I. 10.25.21.docx Supporting Statement A	2021-11-02

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: 202111-0938-002
Status: Received in OIRA	Previous ICR Reference No: 201903-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: ICF/IID Survey Report Form (CMS-3070G-I) and Supporting Regulations
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/03/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2022
Responses	5,758	6,100
Time Burden (Hours)	17,274	18,300
Cost Burden (Dollars)	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
   Statute at Large: 19 Stat. 1902
  

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:
	86 FR 46854	08/20/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 60244	11/01/2021
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-3070H, CMS-3070G, CMS-370I	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report ,   Intermediate Care Facilities for Individuals with Intellectual Disabilities Deficiencies Report ,   Individual Observation Worksheet

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ICR Summary of Burden

	Total Request	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	5,758	6,100	0	0	-342	0
Annual Time Burden (Hours)	17,274	18,300	0	0	-1,026	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: Forms CMS-3070G and CMS-370I have been revised. The responses have decreased from 6,100 to 5,758. The Annual burden hours have decreased from 18,300 to 17,274.

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Annual Cost to Federal Government: $44,096

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 11/03/2021

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