OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Furnishing Nursing Home and Residential Home Care

ICR 200703-2900-008 · OMB 2900-0616 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 10-1170 Application for Furnishing Nursing Home and Residential Home Care Form Modified Available
2900-0616 justification.doc Supporting Statement A Uploaded 0000-00-00 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28869 Application for Furnishing Nursing Home and Residential Home Care Form Modified
ICR Details
2900-0616 200703-2900-008
Historical Active 200402-2900-004
VA 2900-0616
Application for Furnishing Nursing Home and Residential Home Care
Extension without change of a currently approved collection   No
Regular
Approved with change 06/15/2007
Retrieve Notice of Action (NOA) 03/12/2007
OMB approves this collection consistent with the changes described in VA memo on 6/14/07 and revised forms attached.
  Inventory as of this Action Requested Previously Approved
06/30/2010 36 Months From Approved 06/30/2007
1,000 0 1,500
125 0 250
0 0 0
The forms used by VA medical centers and Central Office to determine whether non-Federal nursing home or residential care home meet VA qualifications for providing care to veterans and to assure there is no attempt to defraud the government.
US Code: 38 USC Section 1720 Name of Law: Transfers for nursing home care; adult day health care
   US Code: 38 USC 1730 Name of Law: Community residential care
  
None
Not associated with rulemaking
  71 FR 245 12/21/2006
72 FR 44 03/07/2007
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,000 1,500 0 -500 0 0
Annual Time Burden (Hours) 125 250 0 -84 -41 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Changing Forms
The 41 hour Adjustment is due to a smaller number of sponsors applying for the Residential Care Home Program. The 84 hour Program decrease is a result of simplifying VA Form 10-1170 and utilizing the “CMS’ Nursing Home (NH) Compare” and “Home Health Compare” databases.
$8,136
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Denise McLamb 202-565-8374 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/12/2007