Form 10-0388-4 Space Program Analysis-Adult day Health Care.pdf

SQUARE FOOTAGE

PROPOSED BY

ADMINISTRATOR'S OFFICE

ASSISTANT ADMINISTRATOR

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

GENERAL ADMINISTRATION

CLERICAL STAFF

COMPUTER AREA

CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)

LOBBY/RECEIVING/WAITING AREA

PUBLIC TOILETS (MALE, FEMALE)

DINING AREA

VA FORM

JUL 2013 10-0388-4

1. SUPPORT FACILITIES

MEDICAL SUPPORT (Each)

STATE HOME CONSTRUCTION GRANT PROGRAM

SPACE PROGRAM ANALYSIS - ADULT DAY HEALTH CARE

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

EMPLOYEE TOILETS

EMPLOYEE LOUNGE

EMPLOYEE LOCKERS

MULTIPURPOSE ROOM

JANITORS CLOSET

GENERAL LAUNDRY

GENERAL WAREHOUSE STORAGE (medical, dietary)

RESIDENT STORAGE

BUILDING MAINTENANCE STORAGE

MEDICAL/DIETARY

PARTICIPANT TOILETS (MALE, FEMALE)

TRASH COLLECTION

PARTICIPANT LAUNDRY

CLEAN UTILITY

SOILED UTILITY

PARTICIPANT QUIET ROOM

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

Page 2 of 210-0388-4VA FORM

JUL 2013

GENERAL STORAGE

KITCHENETTE

WHEELCHAIR STORAGE

STAFF TOILET

PROGRAM SUPPLY AND EQUIPMENT

WAITING AREA

EXAMINATION / TREATMENT ROOM

MEDICATION ROOM

1. SUPPORT FACILITIES (Continued)

GRAND TOTAL:

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 OFFICIALNAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE DATE

SQUARE FOOTAGE

PROPOSED BY

OTHER (Justify)

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

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

SQUARE FOOTAGE PROPOSED BY

ADMINISTRATOR'S OFFICE

ASSISTANT ADMINISTRATOR

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

GENERAL ADMINISTRATION

CLERICAL STAFF

COMPUTER AREA

CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)

LOBBY/RECEIVING/WAITING AREA

PUBLIC TOILETS (MALE, FEMALE)

DINING AREA

VA FORM

JUL 2013

10-0388-4

1. SUPPORT FACILITIES

MEDICAL SUPPORT (Each)

STATE HOME CONSTRUCTION GRANT PROGRAM

SPACE PROGRAM ANALYSIS - ADULT DAY HEALTH CARE

OMB Number 2900-0661 Estimated Burden: 2 hours

NURSES' OFFICE AND DICTATION AREA

OFFICE, IF REQUIRED

OCCUPATIONAL THERAPY

OFFICE, IF REQUIRED

PHYSICAL THERAPY

EMPLOYEE TOILETS

EMPLOYEE LOUNGE

EMPLOYEE LOCKERS

MULTIPURPOSE ROOM

JANITORS CLOSET

GENERAL LAUNDRY

GENERAL WAREHOUSE STORAGE (medical, dietary)

RESIDENT STORAGE

BUILDING MAINTENANCE STORAGE

MEDICAL/DIETARY

PARTICIPANT TOILETS (MALE, FEMALE)

TRASH COLLECTION

PARTICIPANT LAUNDRY

CLEAN UTILITY

SOILED UTILITY

PARTICIPANT QUIET ROOM

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

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V A LOGO

10-0388-4

VA FORM

JUL 2013

GENERAL STORAGE

KITCHENETTE

WHEELCHAIR STORAGE

STAFF TOILET

PROGRAM SUPPLY AND EQUIPMENT

WAITING AREA

EXAMINATION / TREATMENT ROOM

MEDICATION ROOM

1. SUPPORT FACILITIES (Continued)

GRAND TOTAL:

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.

SIGNATURE

SQUARE FOOTAGE PROPOSED BY

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