Free VA Form 10-0388-1 - Initial Application for State Home Construction & Acquisition - Federal


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OMB Number: 2900-0661 Estimated Burden: 6 hours

DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS INITIAL APPLICATION
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.

An initial application should be submitted to the Chief Consultant, Geriatrics and Extended Care (114) by April 15, if the state wishes consideration of an initial application for placement on the priority list for the next fiscal year.
SECTION I - DOCUMENTATION REQUIREMENTS

GRANT TYPE
ACQUISITION CONSTRUCTION

1.

Documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully occupied. Applicant's recommendation as to the priority, any sub-priority, and any further priority for purposes of placing the project on the priority list for the next fiscal year (see 38 CFR s 59.50).
SECTION II - STANDARD FORMS

2.

1. 2.

SF 424, APPLICATION (Original and one copy required.) SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS. Include: a. b. Cost estimate for equipment not included in the construction contract (not to exceed 10 percent of the construction costs); and Contingency cost estimate (not to exceed 5 percent of the estimated cost of project for new construction or 8 percent for remodeling projects).

3. 4.

SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS. VA Form 10-0388-2, CERTIFICATION OF COMPLIANCES WITH PROVISIONS OF THE DAVIS-BACON ACT.
SECTION III - ADDITIONAL DOCUMENTATION

1. 2. 3.

Description and scope of the project. Original and one copy required. Project site description, including county location. Governor's letter or a letter from the agency authorized by the governor with program oversight designating the state representative and information that will permit VA to contact the state representative. The state representative must notify the chief consultant (114), immediately of any changes in who the state representative is and how to reach him or her.
SECTION IV - NEEDS ASSESSMENT - Submit information described in either Part A or Part B ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

PARTA

1. 2. 3.

Demographic characteristics of the veteran population of the proposed catchments area. If great travel distances (over two hours) are imposed on veterans and their families, availability of beds. Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.
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VA FORM MAY 2005

10-0388-1

SECTION IV - NEEDS ASSESSMENT - Continued 4. Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal year. Number of community-based nursing home beds and the occupancy rate at those facilities for the previous fiscal year (must have full state certification). The state certification must authorize appropriate level(s) of care to allow veteran placement in those facilities. Waiting lists for existing state home programs. Plans for acute medical care/emergency care services as may be required by the state home residents. Availability of qualified medical care personnel to staff the proposed facility.

PART A-Continued PART B

5. 6. 7. 8.

NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS: 1. 2. Reason for the project. The scope of the project. SECTION V - ADDITIONAL REQUIREMENTS If a state proposes new beds that exceed the maximum number of state home beds as defined in 38 CFR 59.40, the state must provide documentation to justify an exception on the basis of great travel distances (greater than two hours) between a significant population center and an existing state home. The secretary will consider and approve/disapprove such justification in the determination of the priority of the initial application. Authorized state representative's certified statement that the list of the total number of state-operated nursing home and domiciliary beds for veterans is the total number of such beds existing, under construction, or pending approval by VA at the time of the initial application. Schematic drawings for the proposed project. Space program analysis on VA Form 10-0388-3, SPACE PROGRAM ANALYSIS-NURSING HOME AND DOMICILIARY (or VA Form 10-0388-4, SPACE PROGRAM ANALYSIS-ADULT DAY HEALTH CARE) for the proposed project that includes a list of each room or area and the square footage proposed. The plan should note special or unusual services or equipment. The information on VA Form 10-0388-3 (or VA Form 10-0388-4) should correspond with the charts contained in 38 CFR 59.140 and 59.160 State application identifier number (if applicable). DUNS Number. Five-year capital plan for state's entire state home program, including the proposed project. Financial plan for state facility's first three years of operation following construction. Any comments or recommendations made by the appropriate state clearing house pursuant to policies outlined in Executive Order 12372, intergovernmental review of federal programs (part 40 of this chapter). If the state has no clearinghouse, the designated authorized state representative must certify compliance with this executive order. CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION. I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.

1.

2. 3.

4.

5. 6. 7. 8. 9.

NAME OF AUTHORIZED STATE OFFICIAL

TITLE OF AUTHORIZED STATE OFFICIAL

SIGNATURE

DATE (mm/dd/yyyy)

VA FORM MAY 2005

10-0388-1

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