Information Collection

Application for Furnishing Nursing Home and Residential Home Care

IC 28869 under ICR 200703-2900-008 · OMB 2900-0616.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0616 can be found here:

Documents and Forms

Document Name Document Type
Form 10-1170 Application for Furnishing Nursing Home and Residential Home Care Form
10-1170 Application for Furnishing Long-Term Care Services to Be 10-1170-fill.pdf vaww.va.gov/vaforms/ Form
10-2407 Residential Care Home Program - Sponsor Application 10-2407-fill.pdf vaww.va.gov/vaforms/ Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Furnishing Nursing Home and Residential Home Care	Agency IC Tracking Number:	2900-0616

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-1170	Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs	10-1170-fill.pdf	http://vaww.va.gov/vaforms/	No		Fillable Fileable
Form	10-2407	Residential Care Home Program - Sponsor Application	10-2407-fill.pdf	http://vaww.va.gov/vaforms/	No		Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000	-500	0	1,500
Annual IC Time Burden (Hours)	125	-84	-41	250
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

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.