Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 4/8/2014
Individual Observation Worksheet {CMS-3070I}
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Description
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0062 INdIVIdUAL OBSERVATION WORkShEET Name of Facility Date Location/Start Location/Start Time/Start Time/Finish Surveyor Client Codes COLUMN 1 -- TIME COLUMN 2 -- OBSERVATION Form CMS-3070I (10/95) American LegalNet, Inc. www.FormsWorkFlow.com COLUMN 1 -- TIME COLUMN 2 -- OBSERVATION 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. The time required to complete this information collection is estimated to average 3 hours per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-3070I (10/95) American LegalNet, Inc. www.FormsWorkFlow.com
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