Facility and date
Name of Facility and Date.
CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET
- Agency
- CMS
- Revision
- 10/95
- Fillable fields
- 12
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-3070I: Individual Observation Worksheet
Form CMS-3070I is the Individual Observation Worksheet from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. It carries OMB number 0938-0062 and the edition date 10/95.
The worksheet has header fields for the name of the facility, the date, location and start entries, start and finish times, the surveyor and client codes. Below them are two columns, Column 1 for the time and Column 2 for the observation, which continue on a second page. The form prints no further instructions, and the CMS page lists its special instructions as N/A.
The Paperwork Reduction Act notice on the form 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-3070I
Locations and times
Two fields labeled Location/Start, plus Time/Start and Time/Finish.
Surveyor and client codes
The surveyor's name and the client codes.
Time and observation columns
Column 1 for the time and Column 2 for the observation. The columns continue on page 2.
Two pages: a header and a two-column log.
How to fill out Form CMS-3070I
- 1
Enter the facility and date
Type the name of the facility and the date at the top of page 1.
- 2
Record locations and times
Fill in the Location/Start fields and the start and finish times.
- 3
Add surveyor and client codes
Enter the surveyor's name and the client codes.
- 4
Log each observation
Write the time in Column 1 and the observation in Column 2, continuing on page 2 if needed.
Why fill Form CMS-3070I on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
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- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
What the form and the CMS page say
Where it goes
Neither the form nor the CMS page gives a submission address or filing instructions. The CMS address in the Paperwork Reduction Act notice is for comments on the time estimate.
OMB number
The form prints OMB No. 0938-0062. The CMS page lists an OMB expiration date of September 30, 2025.
Time to complete
The form estimates an average of 3 hours per response, including reviewing instructions and gathering the data needed.
Related forms
Who uses Form CMS-3070I?
The form does not state who completes it. Its fields name these roles.
Official sources and the blank
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Questions about Form CMS-3070I
What is Form CMS-3070I?
It is the Individual Observation Worksheet from CMS, a two-page log with a header for the facility, date, times, surveyor and client codes, and columns for the time and the observation.
What does the worksheet record?
Column 1 holds the time and Column 2 the observation. The columns run down page 1 and continue on page 2.
Where is Form CMS-3070I sent?
The form and the CMS page do not give a submission address or filing instructions. The CMS page lists its special instructions as N/A.
How long does Form CMS-3070I take?
The Paperwork Reduction Act notice estimates an average of 3 hours per response.
Which edition is on the CMS page?
The PDF is printed Form CMS-3070I (10/95), and the CMS page gives a revision date of October 1, 1995.