TEMPLATE Needs Assessment 2019.docx

**Note that this is a template, and you are free to adapt as needed. The needs assessment must address items (a-h) as outlined in VA Form 10-0388-1 if the grant application is New Construction or Bed Replacement. Renovation and Life Safety projects do not need to address (a-h) but must include the reason for the project and the scope of the project. The scope of the project listed here should mirror the scope of the project listed in A.1. Project Abstract. Delete any instructions that are italicized once updated. Submit as PDF.**

Checklist Item A.3. Needs Assessment Project Title and/or Description Location (City or County, State)

Adding or replacing nursing home or domiciliary beds

a) Demographic characteristics of the veteran population of the proposed catchments area

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

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

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

e) 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

f) Waiting lists for existing state home programs

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

h) Availability of qualified medical care personnel to staff the proposed facility

NOT adding or replacing nursing home or domiciliary beds

a) Reason for the project

b) Scope of the project