Form 10-0388-3 Space Program Analysis-Nursing Home and Domiciliary.pdf

SQUARE FOOTAGE

PROPOSED BY

ADMINISTRATOR'S OFFICE

ASSTISTANT ADMINISTRATOR

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

GENERAL ADMINISTRATION

CLERICAL STAFF

COMPUTER AREA

CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)

LOBBY/WAITING AREA

PUBLIC TOILETS (MALE, FEMALE)

DINING AREA

CANTEEN, RETAIL SALES

DIETETIC SERVICE

Page 1 of 2VA FORM 10-0388-3

1. SUPPORT FACILITIES

PHARMACY

MEDICAL SUPPORT (Each)

STATE HOME CONSTRUCTION GRANT PROGRAM

SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY

OMB Number 2900-0661 Estimated Burden: 2 hours

NURSES' OFFICE AND DICTATION AREA

PROJECT DESCRIPTION

PROJECT LOCATION FAI NUMBER

OFFICE, IF REQUIRED

OCCUPATIONAL THERAPY

OFFICE, IF REQUIRED

PHYSICAL THERAPY

CHAPEL

EMPLOYEE TOILETS

EMPLOYEE LOUNGE

EMPLOYEE LOCKERS

MULTIPURPOSE ROOM

JANITORS CLOSET

MAIL ROOM

BARBER AND / OR BEAUTY

GENERAL LAUNDRY

GENERAL WAREHOUSE STORAGE (medical, dietary)

RESIDENT STORAGE

BUILDING MAINTENANCE STORAGE

LIBRARY

This form is required for all new construction or general renovations that effect the square footage or floor plan of an existing home. 38.CFR 59-140

JUL 2013

2. BED UNITS

LARGE 2: ROOMS

ONE: ROOMS

TWO: ROOMS

Page 2 of 210-0388-3

LINEN STORAGE

GENERAL STORAGE

SOILED UTILITY

CLEAN UTILITY

RESIDENT QUIET ROOM

LOUNGE AREAS:

KITCHENETTE

STRETCHER / WHEELCHAIR STORAGE

STAFF TOILET

UNIT SUPPLY AND EQUIPMENT

WAITING AREA

EXAMINATION / TREATMENT ROOM

MEDICATION ROOM

OTHER (Justify)

TRASH COLLECTION

RESIDENT LAUNDRY

JANITOR CLOSET

1. SUPPORT FACILITIES (Continued)

PRIVATE OR SHARED FACILITIES

3. BATHING AND TOILET FACILITIES

FULL BATHROOM

CONGREGATE BATHING FACILITIES

GRAND TOTAL:

BATHING AND TOILET FACILITIES

BED UNITS

SUPPORT FACILITIES

COMPREHENSIVE SUB-TOTALS:

TOTALS

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 2 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.

TITLE OF AUTHORIZED STATE OFFICIAL

I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.

NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE DATE

SQUARE FOOTAGE

PROPOSED BY

JUL 2013

VA FORM

JetForm:ANN- 10- 0388- 3.IFD vhacobickoa D:20050112163813- 05'00' D:20050112163813- 05'00'

SQUARE FOOTAGE PROPOSED BY

ADMINISTRATOR'S OFFICE

ASSTISTANT ADMINISTRATOR

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

GENERAL ADMINISTRATION

CLERICAL STAFF

COMPUTER AREA

CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)

LOBBY/WAITING AREA

PUBLIC TOILETS (MALE, FEMALE)

DINING AREA

CANTEEN, RETAIL SALES

DIETETIC SERVICE

VA FORM

10-0388-3

1. SUPPORT FACILITIES

PHARMACY

MEDICAL SUPPORT (Each)

STATE HOME CONSTRUCTION GRANT PROGRAM

SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY

OMB Number 2900-0661 Estimated Burden: 2 hours

NURSES' OFFICE AND DICTATION AREA

OFFICE, IF REQUIRED

OCCUPATIONAL THERAPY

OFFICE, IF REQUIRED

PHYSICAL THERAPY

CHAPEL

EMPLOYEE TOILETS

EMPLOYEE LOUNGE

EMPLOYEE LOCKERS

MULTIPURPOSE ROOM

JANITORS CLOSET

MAIL ROOM

BARBER AND / OR BEAUTY

GENERAL LAUNDRY

GENERAL WAREHOUSE STORAGE (medical, dietary)

RESIDENT STORAGE

BUILDING MAINTENANCE STORAGE

LIBRARY

This form is required for all new construction or general renovations that effect the square footage or floor plan of an existing home. 38.CFR 59-140

JUL 2013

..\logos\FORMLOGO.jpg

V A LOGO

2. BED UNITS

LARGE 2:

ROOMS

ONE:

ROOMS

TWO:

ROOMS

10-0388-3

LINEN STORAGE

GENERAL STORAGE

SOILED UTILITY

CLEAN UTILITY

RESIDENT QUIET ROOM

LOUNGE AREAS:

KITCHENETTE

STRETCHER / WHEELCHAIR STORAGE

STAFF TOILET

UNIT SUPPLY AND EQUIPMENT

WAITING AREA

EXAMINATION / TREATMENT ROOM

MEDICATION ROOM

OTHER (Justify)

TRASH COLLECTION

RESIDENT LAUNDRY

JANITOR CLOSET

1. SUPPORT FACILITIES (Continued)

PRIVATE OR SHARED FACILITIES

3. BATHING AND TOILET FACILITIES

FULL BATHROOM

CONGREGATE BATHING FACILITIES

GRAND TOTAL:

BATHING AND TOILET FACILITIES

BED UNITS

SUPPORT FACILITIES

COMPREHENSIVE SUB-TOTALS:

TOTALS

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 2 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.

I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.

SIGNATURE

SQUARE FOOTAGE PROPOSED BY

JUL 2013

VA FORM