Page 1: facility and deficiencies
Name of facility and a table with columns for 1. Data Tag No., 2. CoP/STND No., and comments describing each deficiency.
CMS-3070H
ICF/IID Deficiencies Report
- Agency
- CMS
- Revision
- 03/13
- Fillable fields
- 65
- Pages
- 4
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-3070H: ICF/IID Deficiencies Report
Form CMS-3070H is the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Deficiencies Report from the Centers for Medicare & Medicaid Services. It is a survey form: surveyors list each deficiency they identify at a facility and sign a certifying statement.
The form tells surveyors to evaluate each of the requirements identified in the ICF/IID Interpretive Guidelines, Appendix J to the SOM. For each deficiency it asks for the data tag number, the regulatory citation and a description of the deficient facility practice and supporting findings. The last page holds certifications for an initial or annual recertification survey and for a follow-up survey.
The form carries OMB number 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-3070H
Page 2: continuation
More rows with the same Data Tag No., CoP/STND No. and comments columns.
Page 3: recertification survey
A certification for an initial or annual recertification survey, choosing Full, Extended or Fundamental Survey, with nine signature, title and date lines.
Page 3: follow-up survey
A certification for a follow-up survey with the date of the earlier survey and nine signature, title and date lines.
Page 4: instructions
Steps A to G for recording each deficiency, adding more space and adding more surveyor signatures, plus the Paperwork Reduction Act statement.
The form is four pages.
How to fill out Form CMS-3070H
- 1
Enter the facility name
Write the name of the facility at the top of page 1.
- 2
Enter the data tag number
For each deficiency, identify the data tag number in the first column.
- 3
Write the regulatory citation
In the second column, write the regulatory citation. If it is a Condition of Participation, enter CoP below the citation.
- 4
Describe the findings
In column three, describe the deficient facility practice and supporting findings, and draw horizontal lines to separate tag numbers.
- 5
Add space if needed
The form says to photocopy the first page, front and back, if more space is needed.
- 6
Sign the certification
Each surveyor signs the certifying statement on the last page. If there are more surveyors than lines, the form says to photocopy the last page and add the signatures.
These steps follow the instructions printed on page 4.
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Reference, OMB number and time
Guidance it refers to
The form says to evaluate each of the requirements identified in the ICF/IID Interpretive Guidelines, Appendix J to the SOM.
Where it goes
The form does not print a submission address.
OMB number
The form shows OMB No. 0938-0062. The CMS page lists an OMB expiration date of 2025-09-30 and a revision date of 2013-03-01.
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-3070H?
The form is completed and signed by surveyors about an ICF/IID facility.
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Questions about Form CMS-3070H
What is Form CMS-3070H?
It is the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Deficiencies Report, where surveyors record deficiencies and sign a certifying statement.
What goes in each column?
The form says the first column holds the data tag number, the second the regulatory citation (with CoP below it for a Condition of Participation), and the third a description of the deficient facility practice and supporting findings.
What if there is not enough space?
The form says to photocopy the first page, front and back.
Who signs Form CMS-3070H?
The form says each surveyor signs the certifying statement on the last page. With more surveyors than lines, it says to photocopy the last page and add the signatures.
Which survey types does the certification cover?
An initial or annual recertification survey marked Full, Extended or Fundamental, and a follow-up survey of items found not in compliance on an earlier date.
How long does the form take?
The form estimates an average of 3 hours per response.