Form 10-0388-1 Initial Application.pdf

OMB Number: 2900-0661 Estimated Burden: 6 hours

2.

3.

SECTION I - STANDARD FORMS

1.

2.

a.

b.

An initial application should be submitted to the State Home Construction Grant Program (SHCGP) by April 15, if the state wishes consideration of an initial application for placement on the priority list for the next fiscal year.

3.

SECTION II - DOCUMENTATION REQUIREMENTS

VA FORM

JUL 2013 10-0388-1 PAGE 1 OF 2

DOCUMENTS AND INFORMATION

REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS

INITIAL APPLICATION

1.

SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS.

FAI NUMBERPROJECT LOCATION

PROJECT DESCRIPTION

4.

SF 424, APPLICATION

Equipment cost estimate is not to exceed 10 percent of the construction costs; and

Contingency cost estimate is not to exceed 5 percent of the estimated cost of project for new construction or 8 percent for remodeling projects).

SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS.

Description and scope of the project, including project site description and 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 SHCGP, immediately of any changes in who the state representative is and how to reach him or her.

Needs Assessment (Must include the following criteria):

ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

b.

c.

d.

e.

f.

g.

h.

a.

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.

The scope of the project.

Reason for the project.

NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

Availability of qualified medical care personnel to staff the proposed facility.

Plans for acute medical care/emergency care services as may be required by the state home residents.

Waiting lists for existing state home programs.

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.

Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal year.

Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.

If great travel distances (over two hours) are imposed on veterans and their families, availability of beds.

Demographic characteristics of the veteran population of the proposed catchments area.

b.

a.

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.

JUL 2013 10-0388-1VA FORM

NAME OF AUTHORIZED STATE OFFICIAL TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)SIGNATURE

SECTION III - ADDITIONAL DOCUMENTATION FOR BED PROJECTS

SECTION II CONTINUED- DOCUMENTATION REQUIREMENTS

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.

6.

7.

5.

Information on VA Form 10-0388-3 and 10-0388-4 should correspond with charts in 140 and 160. Also see the VA community Living Center Design Guide.

Schematic drawings for the proposed project.

State application identifier number (if applicable).

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.

Financial plan for state facility's first three years of operation following construction.

Five-year capital plan for state's entire state home program, including the proposed project.

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.

9.

10.

8.

11.

12.

OMB Number: 2900-0661 Estimated Burden: 6 hours 2.

3.

SECTION I - STANDARD FORMS

1.

2.

a.

b.

An initial application should be submitted to the State Home Construction Grant Program (SHCGP) by April 15, if the state wishes consideration of an initial application for placement on the priority list for the next fiscal year.

3.

SECTION II - DOCUMENTATION REQUIREMENTS

VA FORM

JUL 2013

10-0388-1

DOCUMENTS AND INFORMATION

REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS

INITIAL APPLICATION

1.

SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS.

4.

SF 424, APPLICATION

Equipment cost estimate is not to exceed 10 percent of the construction costs; and Contingency cost estimate is not to exceed 5 percent of the estimated cost of project for new construction or 8 percent for remodeling projects).

SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS.

Description and scope of the project, including project site description and 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 SHCGP, immediately of any changes in who the state representative is and how to reach him or her.

Needs Assessment (Must include the following criteria):

ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

b.

c.

d.

e.

f.

g.

h.

a.

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.

The scope of the project.

Reason for the project.

NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

Availability of qualified medical care personnel to staff the proposed facility.

Plans for acute medical care/emergency care services as may be required by the state home residents.

Waiting lists for existing state home programs.

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.

Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal year.

Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.

If great travel distances (over two hours) are imposed on veterans and their families, availability of beds.

Demographic characteristics of the veteran population of the proposed catchments area.

b.

a.

..\logos\FORMLOGO.jpg

V A LOGO

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.

JUL 2013

10-0388-1

VA FORM

SIGNATURE

SECTION III - ADDITIONAL DOCUMENTATION FOR BED PROJECTS

SECTION II CONTINUED- DOCUMENTATION REQUIREMENTS

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.

6.

7.

5.

Information on VA Form 10-0388-3 and 10-0388-4 should correspond with charts in 140 and 160. Also see the VA community Living Center Design Guide.

Schematic drawings for the proposed project.

State application identifier number (if applicable).

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.

Financial plan for state facility's first three years of operation following construction.

Five-year capital plan for state's entire state home program, including the proposed project.

Documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans thatare 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully occupied.

9.

10.

8.

11.

12.