OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Residential Care Home Program Sponsor Application

ICR 201303-2900-003 · OMB 2900-0616 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-2407 Residential Care Home Program Sponsor Application Form Modified Available
2900-0616 Justification_8-30-2013.doc Supporting Statement A Uploaded 2013-09-04 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28869 Residential Care Home Program Sponsor Application Form Modified
ICR Details
2900-0616 201303-2900-003
Historical Active 201001-2900-001
VA 2900-0616
Application for Residential Care Home Program Sponsor Application
Revision of a currently approved collection   No
Regular
Approved with change 09/06/2013
Retrieve Notice of Action (NOA) 06/27/2013
  Inventory as of this Action Requested Previously Approved
09/30/2016 36 Months From Approved 09/30/2013
500 0 1,000
42 0 125
0 0 0
VA Form 10-2407 is necessary for the residential care home to qualify to provide care to veteran patients. The form covers community providers. Community Nursing Homes (CNHs) already use the form, and the form will cover Home Health and Hospice Care agencies and community adult day health care centers.
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
  78 FR 56 03/22/2013
78 FR 124 06/27/2013
No
1
IC Title Form No. Form Name
Residential Care Home Program Sponsor Application VA Form 10-2407 Residential Care Home Program_Sponsor Application
  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 500 1,000 0 -500 0 0
Annual Time Burden (Hours) 42 125 0 -83 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
VA Form 10-1170 served as the only signed "agreement" between some providers and the VA indicating their intent to participate in the program, comply with CMS standards, and agreeing to a price structure. This program form is no longer required and has been discontinued.
$2,330
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [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.
06/27/2013