Free VA Form 10-0388-3 - State Home Construction Grant Program Space Program Analysis-Nursing Home & Dom - Federal

OMB Number 2900-0661 Estimated Burden: 6 hours

STATE HOME CONSTRUCTION GRANT PROGRAM SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY
PROJECT LOCA TION PROJECT NA M E: FAI# NUMBER OF BEDS IN PROJECT

1. SUPPORT FACILITIES ADMINISTRATOR' S OFFICE ASST. ADMINISTRATOR MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT NURSES' OFFICE AND DICTATION AREA GENERAL ADMINISTRATION (each

PROPOSED BY STATE

VA CRITERIA 200 150 150 120 120 120 120 120 120 120 120 120 120

TOTAL VA ALLOWED

office/person)

MAY INCLUDE: MEDICAL RECORDS SOCIAL SERVICES RECEPTION / INFORMATION CLERICAL STAFF (Each) # COM PUTER A REA CONFERENCE ROOM / CONSULTATION AREA / IN-SERV ICE TRAINING LOBBY/WAITING AREA PUBLIC TOILETS (MALE, FEMALE) PHARMA CY DIETETIC SERVICE DINING AREA CANTEEN, RETAIL SALES VENDING MACHINE RESIDENTS TOILETS CHILD DAYCARE MEDICAL SUPPORT (Each) AR AR AR

120 120 120 80@ 40 500 3/BED (150 min. 600) 25/FIXTURE AS REQUIRED AS REQUIRED 20/BED 2/BED 1/BED (450 max./facility) 25/FIXTURE AS REQUIRED 140 140 140 AR AR AR

STAFF OFFICES (Each) EXAM / TREATMENT (Each) FAMILY COUNSELING (Each)
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1. SUPPORT FACILITIES (Continued) BARBER AND / OR BEAUTY MAIL ROOM JANITORS CLOSET MULTIPURPOSE ROOM EMPLOYEE LOCKERS # EMPL. LOUNGE TOILETS CHAPEL PHYSICAL THERAPY OFFICE, IF REQUIRED OCCUPATIONAL THERAPY OFFICE, IF REQUIRED LIBRARY BUILDING MAINTENANCE STORAGE RESIDENT STORAGE GENERAL WAREHOUSE STORAGE (medical, GENERAL LAUNDRY SUPPORT FACILITIES SUB-TOTAL; (No "As Required" Areas) AS REQUIRED AREAS: 2. BED UNITS ONE # TWO # LARGE 2 # THREE # FOUR # LOUNGE AREAS: ROOMS X ROOMS X ROOMS X ROOMS X ROOMS X @ @ @ @ @ = = = (2 Unit Max) = =

PROPOSED BY STATE

VA CRITERIA 140 120 40 15/BED 6/EMPLOYMENT 120 25/FIXTURE 450 5/BED 120 5/BED 120 1.5/BED 2.5/BED 6/BED

TOTAL VA ALLOWED

dietary)
AR

6/BED AS REQUIRED AR

AR

AS REQUIRED

AR

150 245 305 370 460 8/BED 3/BED 120 105 150 100 260 75 140 50 50 25 /FIXTURE 100 120 Page 2 of 4

RESIDENT LOUNGE W /STORA GE

RESIDENT QUIET ROOM CLEAN UTILITY SOILED UTILITY LINEN STORAGE GENERAL STORA GE NURSES STATION, WARD SECRETARY MEDICATION ROOM EXAMINATION / TREATMENT ROOM WAITING AREA UNIT SUPPLY AND EQUIPMENT STAFF TOILET STRETCHER / WHEELCHAIR STORAGE KITCHENETTE
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1. SUPPORT FACILITIES JANITOR CLOSET RESIDENT LAUNDRY TRASH COLLECTION OTHER (Justify)

(Continued)

PROPOSED BY STATE

VA CRITERIA 40 125 60

TOTAL VA ALLOWED

UNIT SUB-TOTAL: TIMES NO. OF UNITS: X X

SUB TOTAL-ALL BED UNITS: 3. BATHING AND TOILET FACILITIES A. PRIVATE OR SHARED FACILITIES

WHEELCHAIR FACILITIES #

ROOMS X

@=

25/FIXTURE 25/FIXTURE

(50% OF TOTAL, MINIMUM COMPLIANCE WITH UFAS) STANDARD FACILITIES # ROOMS X @=

15/FIXTURE 25/FIXTURE

B. FULL BATHROOM # ROOMS X @

=

75 25/FIXTURE

C. CONGREGATE BATHING FACILITIES FIRST TUB/SHOWER EACH ADDITIONAL FIXTURE# UNIT SUB-TOTAL: TIMES NO.OF UNITS: SUB-TOTAL-ALL UNIT TOILETS NOTE 1: If Bed Units vary in bed numbers, program, or design, reproduce Bed Unit forms, as required (pages 2 & 3), and fill out for each different unit type. NOTE 2: Mechanical, electrical and other engineering/utility areas, in addition to engineering workshops and circulation space, are not included in the Space Analysis or the Percentage of Participation calculations. NOTE 3: All areas not shown on this form must be justified, on a programmatic medical care or state imposed regulatory basis, in order for VA to participate in the funding of that space. TOTALS COMPREHENSIVE SUB-TOTALS SUPPORT FACILITIES - CRITERIA SUPPORT FACILITIES - AS REQUIRED BED UNITS BATHING AND TOILET FACILITIES GRAND TOTALS - CRITERIA AREAS: GRAND TOTALS - AS REQUIRED AREAS: AR AR AR AR PROPOSED BY STATE VA CRITERIA TOTAL VA ALLOWED X X 80 25

If prepared by State: I certify that this accurately reflects the proposed Space Program Analysis for this project
(Signature)
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COMPUTATIONS ANALYSIS CRITERIA AREAS 10% DEVIATION AS REQUIRED AREAS TOTAL STATE PROPOSED: FORMULA FOR % OF VA PARTICIPATION: VA ALLOWED: TOTAL VA ALLOWED:

PROPOSED BY STATE

TOTAL VA ALLOWED

+ +
x.65 =
STATE PROPOSED: AR

+

AR

%

OFFICIAL PERCENTAGE OF VA STATE PROPOSED PARTICIPATION = CERTIFIED DATE

%

State Home Grant Program, Office of Facilities Management (181A) 811 Vermont Avenue, NW, Washington, D.C. 20420

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
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