CMS-370I Individual Observation Worksheet

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0062

ICF/IID SURVEY OBSERVATION WORKSHEET (CMS-3070I)
Name of Facility:

Type of Survey (i.e. - Initial, Recertification, Complaint, Focused, etc.):

Medicare/Medicaid Provider Number:

Observation
Date(s)

Observation
Start & End
Times

Name of
Surveyor(s)
Performing
Observation(s)

Survey Start Date:

Observation
Location(s)

Client
Code(s)

CMS-3070I (Revised XX/XX.202X)/ OMB Approval Expires XX/XX/202X

Survey End Date:

Observations

Page | 1

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0062

ICF/IID SURVEY OBSERVATION WORKSHEET (CMS-3070I)
Name of Facility:

Type of Survey (i.e. - Initial, Recertification, Complaint, Focused, etc.):

Survey Start Date:

Survey End Date:

Observation
Date(s)

Observation
Start & End
Times

Name of
Surveyor(s)
Performing
Observation(s)

Observation
Location(s)

Client
Code(s)

CMS-3070I (Revised XX/XX.202X)/ OMB Approval Expires XX/XX/202X

Observations

Page | 2

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0062

ICF/IID SURVEY OBSERVATION WORKSHEET (CMS-3070I)
ICF/IID SURVEY OBSERVATION WORKSHEET (CMS-3070I)
Name of Facility:

Type of Survey (i.e. - Initial, Recertification, Complaint, Focused, etc.):

Survey Start Date:

Survey End Date:

Observation
Date(s)

Observation
Start & End
Times

Name of
Surveyors
Performing
Observation(s)

Observation
Location(s)

Client
Code(s)

CMS-3070I (Revised XX/XX.202X)/ OMB Approval Expires XX/XX/202X

Observations

Page | 3

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0062

ICF/IID SURVEY OBSERVATION WORKSHEET (CMS-3070I)

CMS-3070I (Revised XX/XX.202X)/ OMB Approval Expires XX/XX/202X

Page | 4

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0062

INSTRUCTIONS
1. The CMS-3070I form can be used to document one or more observations made during a single survey.
2. Make a separate entry for each observation made, which includes the following information:
a. Observation Date: Document the date each observation is performed.
b. Observation Start & End Times: Document the start and end times for each observation.
c. Name of Surveyor(s) Performing Observation(s): Record the name of the surveyor(s) who performed each observation.
d. Observation Location(s): Record the location where each observation took place.
e. Client Code: Do not document the names of persons involved in each observation. Instead, assign client codes to each person. For example if
several patients are observed, the client codes could be “Patient A”, “Patient B”, “Patient C”, etc. If facility staff are involved in an observation, the
client codes could be “RN1”, “RN2”, “RN3”, or “Therapist 1”, “Counselor 1”, “Nursing Assistant 1” etc. If the observation involves patient family
members, the client codes could be “Family Member A”, “Family Member B”, etc. Make sure to use a different code for each person observed and do
not repeat codes already used.
f.

Observations: Record details about the observations made

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0062 (Expires XX/XX/202X). This is a mandatory information collection. The
time required to complete this information collection is estimated to average 72 hours per response, which includes completion of the survey and the CMS-3007G,
CMS-3070H & CMS-3070I forms, and which also includes the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments, regarding the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.
Please note that any correspondence not pertaining to the information collection burden, approved under the OMB control number listed on this form, will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Donald Howard at
QSOG_ICFIID@cms.hhs.gov.

CMS-3070I (Revised XX/XX.202X)/ OMB Approval Expires XX/XX/202X

Page | 5