Blocks 1 to 11: Facility and survey
Facility name, street address, city or county, state, ZIP code, Medicaid provider number, CEO, phone, State/Region and State/County codes, and survey begin and end dates (mm/dd/yyyy).
CMS-3070G
ICF/IID Survey Report
- Agency
- CMS
- Revision
- 03/13
- Fillable fields
- 174
- Pages
- 4
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-3070G: ICF/IID Survey Report
Form CMS-3070G is the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Survey Report from the Centers for Medicare & Medicaid Services. It records one survey of an ICF/IID: the facility's identity and ownership, who was on the survey team, facility and staffing data, off-campus day programs, and counts of client characteristics.
Most entries carry a code from W2 to W74. The last section counts allegations of abuse and neglect investigated and deaths, and comes with data entry instructions that quote the definitions of abuse and neglect in 42 CFR 488.301. The form carries OMB No. 0938-0062 and estimates an average of 3 hours per response.
You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-3070G
Blocks 12 to 14: Ownership
Type of ownership or control from seven numbered choices, and whether the ICF/IID is a distinct part of a hospital, SNF or NF, with its provider number.
Block 15: Survey team
The number of surveyors from each discipline, from administrator to psychologist and other, and the totals of surveyors and QIDP surveyors onsite.
Blocks 16 to 18: Facility, staffing, day programs
Beds, clients, whether the ICF/IID is community-based, living units, client age range and off-campus day program sites; full time equivalents for direct care personnel and nurses; and day program attendance and observations.
Block 19, A to L: Individual characteristics
Counts of clients by age and sex, level of intellectual disability, autism, cerebral palsy, epilepsy, other disabilities, drugs to control behavior, physical restraints, time-out rooms, court-ordered admissions and more.
Block 19, M and N: Allegations and deaths
The number of allegations of abuse and of neglect investigated, and the number of deaths related to unusual incidents, to restraints, and for any other reason.
How to fill out Form CMS-3070G
- 1
Enter the facility and survey details
Fill in blocks 1 to 11, including the survey begin and end dates in mm/dd/yyyy format.
- 2
Record ownership and distinct part status
Enter the ownership number in block 12 and answer blocks 13 and 14.
- 3
Describe the survey team
Count each discipline in block 15, column 1, and those who also qualify as a QIDP in column 2. The form asks for names and titles on its last page.
- 4
Add facility, staffing and day program data
Complete blocks 16 to 18. If the answer to 16A is No, the form says to go to item C.
- 5
Count individual characteristics
Complete block 19 A to L. The form notes the totals in items B to L may exceed the facility's population because some clients have multiple disabilities.
- 6
Report allegations and deaths
Follow the data entry instructions for sections M and N. If there is nothing to report, they say to leave the field blank. Totals W70 and W74 are program generated.
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What the form says
Where it goes
The form does not print a submission address. The CMS address in its Paperwork Reduction Act statement is for comments on the time estimate only.
Allegations counted
The data entry instructions say to count allegations of abuse or neglect investigated, including investigations resulting from complaints, follow ups, initials or recertifications.
Deaths counted
W71 counts unexpected or unanticipated deaths from unusual incidents, W72 deaths from the use of restraints, and W73 deaths for any reason not included in W71 and W72.
Time to complete
The form estimates an average of 3 hours per response, including reviewing instructions, gathering the data and completing the form.
Related forms
Who uses Form CMS-3070G?
The form does not name who fills it out. Its blocks describe the facility surveyed and the survey team.
Official sources and the blank
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Questions about Form CMS-3070G
What does ICF/IID stand for?
The form's title spells it out: Intermediate Care Facilities for Individuals with Intellectual Disabilities.
What are the W codes on Form CMS-3070G?
The form labels its entries with codes from W2 to W74, and its data entry instructions refer to fields by those codes.
How does the form define abuse and neglect?
Quoting 42 CFR 488.301, it defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, and neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.
Do I enter the totals in W70 and W74?
No. The data entry instructions say those totals are program generated, so no data input is necessary.
Why can disability counts exceed the number of clients?
The form notes that the totals in items B to L may exceed the facility's population because some clients have multiple disabilities.
How long does Form CMS-3070G take?
The form estimates an average of 3 hours per response.