Information Collection

Title 38, Parts 51 and 52, State Home Program

IC 28394 under ICR 200608-2900-010 · OMB 2900-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0160 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0144A Title 38, Parts 51 and 52, State Home Program	Form
10-10SH State Home Program Application for Veteran Care Medical 2900-0160 VA Form 10-10SH.pdf www.va.gov/vaforms/	Form
10-3567 State Home Inspection Staffing Profile 2900-0160 VA Form 10-3567.pdf www.va.gov/vaforms/	Form
10-5588 State Home Report and Statement of Federal Aid Claimed 2900-0160 VA Form 10-5588.pdf www.va.gov/vaforms/	Form
10-0143 Department of Veterans Affairs Certification Regarding D 2900-0160 VA Form 10-0143.pdf www.va.gov/vaforms/	Form
10-0143A Statement of Assurance of Compliance with Section 504 of 2900-0160 VA Form 10-0143A.pdf www.va.gov/vaforms/	Form
10-0144 Certification Regarding Lobbying 2900-0160 VA Form 10-0144.pdf www.va.gov/vaforms/	Form
10-0144A Statement of Assurance of Compliance with Equal Opportun 2900-0160 VA Form 10-0144A.pdf www.va.gov/vaforms/	Form

IC Title:

Title 38, Parts 51 and 52, State Home Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 51 38 CFR 52

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0144A	Statement of Assurance of Compliance with Equal Opportunity Laws	2900-0160 VA Form 10-0144A.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0144	Certification Regarding Lobbying	2900-0160 VA Form 10-0144.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-3567	State Home Inspection Staffing Profile	2900-0160 VA Form 10-3567.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0143	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	2900-0160 VA Form 10-0143.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0143A	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	2900-0160 VA Form 10-0143A.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-5588	State Home Report and Statement of Federal Aid Claimed	2900-0160 VA Form 10-5588.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-10SH	State Home Program Application for Veteran Care Medical Certification	2900-0160 VA Form 10-10SH.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45,138

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47,658	2,137	45,521
Annual IC Time Burden (Hours)	15,535	408	15,127
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.