Application for Furnishing Nursing Home and Residential Home Care

Forms and Documents

Document Name	Status
Form 10-1170 Application for Furnishing Nursing Home and Residential Home Care Form	Modified
2900-0616 justification.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
28869	Application for Furnishing Nursing Home and Residential Home Care Form	Modified

ICR Details

OMB Control No: 2900-0616	ICR Reference No: 200703-2900-008
Status: Historical Active	Previous ICR Reference No: 200402-2900-004
Agency/Subagency: VA	Agency Tracking No: 2900-0616
Title: Application for Furnishing Nursing Home and Residential Home Care
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/15/2007
	Date Received in OIRA: 03/12/2007
Terms of Clearance: 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
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	1,000	0	1,500
Time Burden (Hours)	125	0	250
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 245	12/21/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 44	03/07/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Furnishing Nursing Home and Residential Home Care	10-1170, 10-2407	Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs ,   Residential Care Home Program - Sponsor Application

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: 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.

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Annual Cost to Federal Government: $8,136

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/12/2007

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