Free VA Form 10-0408 - VHA Fisher House Application (Fillable) - Federal

OMB Number 2900-0630 Estimated burden 10 minutes

VHA FISHER HOUSE APPLICATION
VETERANS INTEGRATED SERVICE NETWORK (VISN) # NAME OF VETEANS HEALTH ADMINISTRATION (VHA) FACILITY

DATE (dd/mm/yyyy)

LOCATION OF VHA FACILITY

FACILITY CONTACT PERSON NAME TITLE TELEPHONE NUMBER

FACILITY DIRECTOR OR CHIEF EXECUTIVE OFFICER 1. PROVIDE A FULL DESCRIPTION OF THE PROPOSED LOCATION, INCLUDING SIZE OF LOT (RECOMMENDED AT APPROXIMATELY ONE ACRE) AND LOCATION IN RELATION TO THE VHA FACILITY. (NOTE: Ideally, the proposed site should be accessible to patient treatment buildings.) PROVIDE A SKETCHED DRAWING OF THE PROPOSED SITE. PROVIDE AS ATTACHMENT LABELED AS "RESPONSE TO ITEM 1". 2. THE APPROXIMATE WALKING TIME FROM THE PROPOSED SITE TO PATIENT TREATMENT BUILDINGS IS 3. IDENTIFY ANY SPECIAL CONSTRUCTION ISSUES OR NEEDS FOR THE PROPOSED SITE. PROVIDE AS ATTACHMENT LABELED AS "RESPONSE TO ITEM 3".

4. I COMMIT TO FUNDING SITE PREPARATION FOR THE PROPOSED FISHER HOUSE

YES

NO

5. I COMMIT TO FUNDING FULL OPERATIONAL COSTS OF THE PROPOSED FISHER HOUSE, INCLUDING ALL UTILITIES AND MAINTENANCE OF THE STRUCTURE AND UTILITIES 6. I COMMIT TO FUNDING PROVIDING ONE FULL-TIME EQUIVALENT (FTE) EMPLOYEE TO SERVE AS THE FISHER HOUSE MANAGER.

YES

NO

YES

NO

7. WHAT SPECIALIZED MEDICAL OR MENTAL HEALTH SERVICES (SURGERY, TRANSPLANT, CANCER TREATMENTS, ETC.) DOES YOUR FACILITY PROVIDE THAT SUPPORT THE NEED FOR A FISHER HOUSE? PROVIDE A BRIEF STATEMENT DESCRIBING INPATIENT AND OUTPATIENT TREATMENT PROGRAMS OFFERED BY YOUR FACILITY EXPECTED TO BE THE PRIMARY SOURCES OF PATIENTS AND/OR FAMILIES SUPPORTED BY THE FISHER HOUSE. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 7". 8. PROVIDE WORKLOAD INFORMATION, AS FOLLOWS: 8A. NUMBER OF UNIQUE VETERANS SERVED IN PREVIOUS FISCAL YEAR

8B. NUMBER OF OUTPATIENT VISITS IN PREVIOUS FISCAL YEAR

8C. NUMBER OF INPATIENT ADMISSIONS IN PREVIOUS FISCAL YEAR.

8D. OTHER RELEVANT WORKLOAD NUMBERS

9. DOES THE WORKLOAD (NUMBER OF UNIQUE VETERANS SERVED, INAPTIENT ADMISSIONS AND OUTPATIENT VISITS) JUSTIFY THE NEED FOR A FISHER HOUSE? VA FORM SEP 2005 (R)

YES

NO

10-0408

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VHA FISHER HOUSE APPLICATION CON'T
10A. DESCRIBE THE CATCHMENT AREA AND PATIENT POPULATION SERVED. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 10A". 10B. IS YOUR FACILITY A REFERRAL CENTER FOR VISN OR AN INTEGRATED FACILITY? 11A. DESCRIBE THE GEOGRAPHIC CATCHMENT AREA IN TERMS OF SQUARE MILES. 11B. DO VETERANS RECEIVING CARE FROM YOUR FACILITY INCUR LONG-DISTANCE TRAVEL? 12A. COULD THE TEMPORARY LODGING REQUIREMENTS BE MANAGED WITH EXISTING HOSPTIAL SPACE? 12B. COULD THE TEMPORARY LODGING REQUIREMENTS BE MANAGED WITH A PUBLIC-PRIVATE VENTURE DEVELOPMENT ON THE DESIRED SITE THROUGH THE ENHANCED-USE PROGRAM? YES NO NO YES YES NO

NO

YES

13A. WHAT ARE THE AVERAGE LOCAL HOTEL AND/OR MOTEL COSTS?

13B.HAS THE FACILITY NEGOTIATED SPECAL RATES FOR VETERANS AND THEIR FAMILY MEMBERS AT LOCAL HOTELS AND/OR MOTELS? 13C. ARE THE HOTEL AND/OR MOTEL RATES COST PROHIBITIVE FOR THE PATIENT POPULATION SERVED?

NO

YES

NO

YES

14. ARE THERE POTENTIAL SPONSOR AND/OR ENDORSEMENTS FOR FINANCIAL SUPPORT TO AID IN THE INITIAL CONSTRUCTION COSTS? 15. ARE THERE POTENTIAL SPONSOR AND/OR ENDORSEMENTS FOR FINANCIAL SUPPORT TO AID IN THE RECURRING OPERATIONAL COSTS?

NO

YES

NO

YES

16. DESCRIBE ANY STATE GRANTS OR LOCAL FINANCIAL AND/OR VOLUNTEER SUPPORT FOR INITIAL FUNDING AS WELL AS FOR CONTINUED OPERATIONAL SUPPORT. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 16". 17. ATTACH ANY LETTERS OF ENDORSEMENT FROM VETERANS' SERVICE ORGANIZATIONS AND YOUR FACILITY CHIEF OF VOLUNTARY SERVICE. PROVIDE AS ATTACHMENT LABELED AS "RESPONSE TO ITEM 17". 18. ATTACH ANY LETTERS OF ENDORSEMENT FROM COMMUNITY LEADERS AND STATE AND FEDERAL POLITICIANS. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 18".

I support this application for a VA Fisher House

(Signature of Facility Director or Chief Executive Officer) I recommend this application for a VA Fisher House

(Date)

(Signature of VISN Director)
VA FORM SEP 2005 (R)

(Date)

10-0408

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PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION

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. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. The information on this form is solicited under the authority of Public Law 106-419, the Veterans Benefits and Health Care Act of 2000. These statutory provisions have been codified at 38 USC 1708, and are administered by the Department of Veterans Affairs. We anticipate that the time expended by all individuals who must complete this form will average 10 minutes. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. Completion of this form is entirely voluntary. However, if you do not provide the requested information, it may not be possible for VA to determine your eligibility for temporary lodging. Failure to furnish this information will have no adverse impact on any benefits to which you may have been entitled. The purpose of this form is to determine eligibility for temporary lodging while the veteran undergoes extensive treatment or procedures. Information may be disclosed outside the VA as permitted by law. Possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA19 "Patient Medical Record - VA", published in the Federal Register (and as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html.) in accordance with the Privacy Act of 1974.

VA FORM SEP 2005 (R)

10-0408

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