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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-1170	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 %

table that charts list of burden
	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

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.