OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Residential Care Home Program Sponsor Application

ICR 201602-2900-040 · 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_092816.doc Supporting Statement A Uploaded 2016-09-28 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28869 Residential Care Home Program Sponsor Application Form Modified
ICR Details
2900-0616 201602-2900-040
Historical Active 201303-2900-003
VA 2900-0616
Application for Residential Care Home Program Sponsor Application
Extension without change of a currently approved collection   No
Regular
Approved without change 02/06/2017
Retrieve Notice of Action (NOA) 09/28/2016
  Inventory as of this Action Requested Previously Approved
02/29/2020 36 Months From Approved 02/28/2017
500 0 500
42 0 42
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
  81 FR 40767 06/22/2016
81 FR 22073 09/14/2016
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 500 500 0 0 0 0
Annual Time Burden (Hours) 42 42 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$2,400
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [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.
09/28/2016