Free VA Form 10-0388-4 - State Home Construction Grant Program-Adult Day Health Care - Federal



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OMB Number 2900-0661 Estimated Burden: 6 hours STATE HOME CONSTRUCTION GRANT PROGRAMADULT DAY HEALTH CARE PROJECT LOCATION PROJECT NAME: FAI# Number of Participants in Program PROPOSED BY STATE NUMBER BEDS IN PROJECT VA CRITERIA 200 150 150 120 120 120 120 120 120 120 120 120 120 MAY INCLUDE: MEDICAL RECORDS SOCIAL SERVICES RECEPTION / INFORMATION CLERICAL STAFF (Each) # COMPUTER AREA CONFERENCE ROOM / CONSULTATION AREA/IN-SERVICE TRAINING LOBBY / WAITING AREA PUBLIC TOILETS (MALE, FEMALE) DIETETIC SERVICE DINING AREA CANTEEN, RETAIL SALES VENDING MACHINE PARTICIPANTS TOILETS MEDICAL SUPPORT (Each) AR 120 120 120 80@ 40 500 3/PARTICIPANT (150 min. 600 25/FIXTURE AS REQUIRED 20/PARTICIPANT 2/PARTICIPANT 1/PARTICIPANT 25/FIXTURE 140@ 140 140 140 140 140 MAIL ROOM JANITORS CLOSET VA FORM MAR 2005 120 40 Page 1 of 4 AR TOTAL VA ALLOWED 1. SUPPOR

OMB Number 2900-0661 Estimated Burden: 6 hours

STATE HOME CONSTRUCTION GRANT PROGRAMADULT DAY HEALTH CARE
PROJECT LOCATION PROJECT NAME: FAI# Number of Participants in Program PROPOSED BY STATE NUMBER BEDS IN PROJECT VA CRITERIA 200 150 150 120 120 120 120 120 120 120 120 120 120 MAY INCLUDE: MEDICAL RECORDS SOCIAL SERVICES RECEPTION / INFORMATION CLERICAL STAFF (Each) # COMPUTER AREA CONFERENCE ROOM / CONSULTATION AREA/IN-SERVICE TRAINING LOBBY / WAITING AREA PUBLIC TOILETS (MALE, FEMALE) DIETETIC SERVICE DINING AREA CANTEEN, RETAIL SALES VENDING MACHINE PARTICIPANTS TOILETS MEDICAL SUPPORT (Each) AR 120 120 120 80@ 40 500 3/PARTICIPANT (150 min. 600 25/FIXTURE AS REQUIRED 20/PARTICIPANT 2/PARTICIPANT 1/PARTICIPANT 25/FIXTURE 140@ 140 140 140 140 140 MAIL ROOM JANITORS CLOSET VA FORM MAR 2005 120 40 Page 1 of 4 AR TOTAL VA ALLOWED

1. SUPPORT FACILITIES ADMINISTRATOR'S OFFICE ASST. ADMINISTRATOR

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT NURSES' OFFICE AND DICTATION AREA GENERAL ADMINISTRATION (each

office/person)

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1. SUPPORT FACILITIES (Continued) MULTIPURPOSE ROOM EMPLOYEE LOCKERS # EMPL. LOUNGE TOILETS 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. OTHER AREAS RESIDENT QUIET ROOM CLEAN UTILITY SOILED UTILITY LINEN STORAGE GENERAL STORAGE NURSES STATION, WARD SECRETARY MEDICATION ROOM EXAMINATION/TREATMENT ROOM WAITING AREA PROGRAM SUPPLY AND EQUIPMENT STAFF TOILET STRETCHER/WHEELCHAIR STORAGE KITCHENETTE JANITOR CLOSET RESIDENT LAUNDRY TRASH COLLECTION OTHER (Justify) UNIT SUB-TOTAL: TIMES NO. UNITS:

PROPOSED BY STATE

VA CRITERIA 15/PARTICIPANT 6/EMPL. 120 25/FIXTURE 5/PARTICIPANT 120 5/PARTICIPANT 120 1.5/PARTICIPANT 2.5/PARTICIPANT 6/PARTICIPANT

TOTAL VA ALLOWED

dietary)

AR

6/PARTICIPANT AS REQUIRED

AR

AR

AS REQUIRED

AR

3/PARTICIPANT 120 105 150 100 260 75 140 50 50 25/FIXTURE 100 120 40 120 60

x

x

SUB TOTAL:

VA FORM MAR 2005

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3. BATHING AND TOILET FACILITIES A. PRIVATE OF SHARED FACILITIES

PROPOSED BY STATE

VA CRITERIA

TOTAL VA ALLOWED

WHEELCHAIR FACILITIES #

ROOMS X

@=

25/FIXTURE 25/FIXTURE

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

15/FIXTURE 25/FIXTURE

FULL BATHROOM #

ROOMS X

@=

75 25/FIXTURE

CONGREGATE BATHING FACILITIES - FIRST TUB/SHOWER EACH ADDITIONAL FIXTURE # UNIT SUB-TOTAL: TIMES NO. OF UNITS: SUB-TOTAL - ALL UNIT TOILETS NOTE 1:

80 25

x x

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 2: 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 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

If prepared by State:

I certify that this accurately reflects the proposed Space Program Analysis for this project:
Signature COMPUTATIONS PROPOSED BY STATE Date (mm/dd/yyyy) ALLOWED BY VA

ANALYSIS CRITERIA AREAS 10% DEVIATION AS REQUIRED AREAS TOTAL STATE PROPOSED: FORMULA FOR % OF VA PARTICIPATION: VA ALLOWED:

+
TOTAL VA ALLOWED:

+ +

x 0.65 = % %

STATE PROPOSED: OFFICIAL PERCENTAGE OF VA PARTICIPATION

CERTIFIED State Home Grant Program, Office of Facilities Management (181A), 811 Vermont Avenue, NW, Washington, D.C. 20420 VA FORM MAR 2005 Date (mm/dd/yyyy) Page 3 of 4

10-0388-4

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.
VA FORM MAR 2005

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Pa ge 4 of 4

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State: Federal
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URL

http://www.va.gov/vaforms/medical/pdf/10-0388-4-fillable.pdf