Form VA form 10-0408 VA form 10-0408 VHA Fisher House Application

OMB Number 2900-0630
Estimated Burden 10 minutes

VHA FISHER HOUSE APPLICATION
VETERANS INTEGRATED
SERVICE NETWORK (VISN) #

NAME OF VETERANS HEALTH ADMINISTRATION (VHA) FACILITY

DATE (dd/mm/yyyy)

LOCATION OF VHA FACILITY

FACILITY CONTACT PERSON
NAME

TITLE

TELEPHONE NUMBER

FACILITY DIRECTOR OR CHIEF EXECUTIVE OFFICER
1. PROVIDE A FULL DESCRIPTION OF THE PROPOSED LOCATION, INCLUDING SIZE OF LOT (RECOMMENDED AT APPROXIMATELY ONE ACRE)
AND LOCATION IN RELATION TO THE VHA FACILITY. (NOTE: Ideally, the proposed site should be accessible to patient treatment buildings.) PROVIDE
A SKETCHED DRAWING OF THE PROPOSED SITE. PROVIDE AS ATTACHMENT LABELED AS "RESPONSE TO ITEM 1".
2. THE APPROXIMATE WALKING TIME FROM THE PROPOSED SITE TO PATIENT TREATMENT BUILDINGS IS
3. IDENTIFY ANY SPECIAL CONSTRUCTION ISSUES OR NEEDS FOR THE PROPOSED SITE. PROVIDE AS ATTACHMENT LABELED AS
"RESPONSE TO ITEM 3".

4. I COMMIT TO FUNDING SITE PREPARATION FOR THE PROPOSED FISHER HOUSE

YES

NO

5. I COMMIT TO FUNDING FULL OPERATIONAL COSTS OF THE PROPOSED FISHER HOUSE,
INCLUDING ALL UTILITIES AND MAINTENANCE OF THE STRUCTURE AND UTILITIES

YES

NO

6. I COMMIT TO FUNDING PROVIDING ONE FULL-TIME EQUIVALENT (FTE) EMPLOYEE TO
SERVE AS THE FISHER HOUSE MANAGER.

YES

NO

7. WHAT SPECIALIZED MEDICAL OR MENTAL HEALTH SERVICES (SURGERY, TRANSPLANT, CANCER TREATMENTS, ETC.) DOES YOUR
FACILITY PROVIDE THAT SUPPORT THE NEED FOR A FISHER HOUSE? PROVIDE A BRIEF STATEMENT DESCRIBING INPATIENT AND
OUTPATIENT TREATMENT PROGRAMS OFFERED BY YOUR FACILITY EXPECTED TO BE THE PRIMARY SOURCES OF PATIENTS AND/OR
FAMILIES SUPPORTED BY THE FISHER HOUSE. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 7".
8. PROVIDE WORKLOAD INFORMATION, AS FOLLOWS:
8A. NUMBER OF UNIQUE VETERANS SERVED IN PREVIOUS FISCAL YEAR

8B. NUMBER OF OUTPATIENT VISITS IN PREVIOUS FISCAL YEAR

8C. NUMBER OF INPATIENT ADMISSIONS IN PREVIOUS FISCAL YEAR.

8D. OTHER RELEVANT WORKLOAD NUMBERS

9. DOES THE WORKLOAD (NUMBER OF UNIQUE VETERANS SERVED, INPATIENT ADMISSIONS AND
OUTPATIENT VISITS) JUSTIFY THE NEED FOR A FISHER HOUSE?
VA FORM
SEP 2005 (R)

10-0408

YES

NO

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VHA FISHER HOUSE APPLICATION CON'T
10A. DESCRIBE THE CATCHMENT AREA AND PATIENT POPULATION SERVED. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO
ITEM 10A".
10B. IS YOUR FACILITY A REFERRAL CENTER FOR VISN OR AN INTEGRATED FACILITY?

YES

NO

11B. DO VETERANS RECEIVING CARE FROM YOUR FACILITY INCUR LONG-DISTANCE TRAVEL?

YES

NO

12A. COULD THE TEMPORARY LODGING REQUIREMENTS BE MANAGED WITH EXISTING HOSPTIAL SPACE?

NO

YES

NO

YES

13B.HAS THE FACILITY NEGOTIATED SPECAL RATES FOR VETERANS AND THEIR FAMILY MEMBERS AT
LOCAL HOTELS AND/OR MOTELS?

NO

YES

13C. ARE THE HOTEL AND/OR MOTEL RATES COST PROHIBITIVE FOR THE PATIENT POPULATION SERVED?

NO

YES

NO

YES

NO

YES

11A. DESCRIBE THE GEOGRAPHIC CATCHMENT AREA IN TERMS OF SQUARE MILES.

12B. COULD THE TEMPORARY LODGING REQUIREMENTS BE MANAGED WITH A PUBLIC-PRIVATE
VENTURE DEVELOPMENT ON THE DESIRED SITE THROUGH THE ENHANCED-USE PROGRAM?

13A. WHAT ARE THE AVERAGE LOCAL HOTEL AND/OR MOTEL COSTS?

14. ARE THERE POTENTIAL SPONSOR AND/OR ENDORSEMENTS FOR FINANCIAL SUPPORT TO AID
IN THE INITIAL CONSTRUCTION COSTS?
15. ARE THERE POTENTIAL SPONSOR AND/OR ENDORSEMENTS FOR FINANCIAL SUPPORT TO AID
IN THE RECURRING OPERATIONAL COSTS?

16. DESCRIBE ANY STATE GRANTS OR LOCAL FINANCIAL AND/OR VOLUNTEER SUPPORT FOR INITIAL FUNDING AS WELL AS FOR
CONTINUED OPERATIONAL SUPPORT. PROVIDE AN ATTACHMENT LABELED AS "RESPONSE TO ITEM 16".
17. ATTACH ANY LETTERS OF ENDORSEMENT FROM VETERANS' SERVICE ORGANIZATIONS AND YOUR FACILITY CHIEF OF VOLUNTARY
SERVICE. PROVIDE AS ATTACHMENT LABELED AS "RESPONSE TO ITEM 17".
18. ATTACH ANY LETTERS OF ENDORSEMENT FROM COMMUNITY LEADERS AND STATE AND FEDERAL POLITICIANS. PROVIDE AN
ATTACHMENT LABELED AS "RESPONSE TO ITEM 18".

I support this application for a VA Fisher House

(Signature of Facility Director or Chief Executive Officer)

(Date)

I recommend this application for a VA Fisher House

(Signature of VISN Director)
VA FORM
SEP 2005 (R)

10-0408

(Date)

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PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of this Act. We may not conduct or sponsor, and
you are not required to respond to, a collection of information unless it displays a valid OMB number. The
information on this form is solicited under the authority of Public Law 106-419, the Veterans Benefits and
Health Care Act of 2000. These statutory provisions have been codified at 38 USC 1708, and are
administered by the Department of Veterans Affairs. We anticipate that the time expended by all individuals
who must complete this form will average 10 minutes. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form. Completion of this form is entirely voluntary.
However, if you do not provide the requested information, it may not be possible for VA to determine your
eligibility for temporary lodging. Failure to furnish this information will have no adverse impact on any
benefits to which you may have been entitled. The purpose of this form is to determine eligibility for
temporary lodging while the veteran undergoes extensive treatment or procedures. Information may be
disclosed outside the VA as permitted by law. Possible disclosures include those described in the "routine
uses" identified in the VA system of records 24VA19 “Patient Medical Record - VA”, published in the
Federal Register (and as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at
http://www.access.gpo.gov/su_docs/aces/2003_pa.html.) in accordance with the Privacy Act of 1974.

VA FORM
SEP 2005 (R)

10-0408

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