Form Cms-3070i - Individual Observation Worksheet

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
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)

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