Title 38, Parts 51 and 52, State Home Programs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-3567 State Home Inspection Staffing Profile	Form	Modified	Available
Form 10-0460 Request for Prescription Drugs from an Eligible Veteran in a State Home	Form	Modified	Available
Form 10-5588 State Home report and Statement of Federal Aid Claimed	Form	Modified	Available
Form 10-10SH State Homes Program Application for Veterans Care Medical Certification	Form	Modified	Available
Form 10-0144A Statement of Assurance of Compliance with Equal Opportunity Laws	Form	Modified	Repair queued
Form 10-0144 Certification Regarding Lobbying	Form	Modified	Available
Form 10-0143A Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	Form	Modified	Repair queued
Form 10-0143 Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	Form	Modified	Available
2900-0160 justification.docx	Supporting Statement A	Uploaded 2012-10-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	State Home Inspection Staffing Profile
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	Request for Prescription Drugs from an Eligible Veteran in a State Home
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	State Home report and Statement of Federal Aid Claimed
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	State Homes Program Application for Veterans Care Medical Certification
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	Statement of Assurance of Compliance with Equal Opportunity Laws
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	Certification Regarding Lobbying
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973
28394	Title 38, Parts 51 and 52, State Home Program	Form	Modified	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals

ICR Details

OMB Control No: 2900-0160	ICR Reference No: 201207-2900-004
Status: Historical Active	Previous ICR Reference No: 200906-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0160
Title: Title 38, Parts 51 and 52, State Home Programs
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 without change	Conclusion Date: 01/14/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/22/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	47,838	0	47,838
Time Burden (Hours)	15,550	0	15,550
Cost Burden (Dollars)	0	0	0

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Abstract: To ensure per diem payments are limited to facilities providing high quality care. To determine eligibility for care, to determine payment due State Homes, Nursing Homes, State Hospitals, and Adult Day Health Care (ADHC) providing care to veterans.

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Authorizing Statute(s): PL: Pub.L. 109 - 461 211(a)(5) Name of Law: Veterans Benefits, Health Care, and Information Technology - Modification to State Home Authorities
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AM97	Final or interim final rulemaking	74 FR 81	04/29/2009

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 45719	08/01/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 64386	10/19/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Title 38, Parts 51 and 52, State Home Program	10-0144A, 10-0143, 10-0143A, 10-0144, 10-5588, 10-0460, 10-10SH, VA Form 10-3567	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals ,   Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973 ,   Certification Regarding Lobbying ,   Statement of Assurance of Compliance with Equal Opportunity Laws ,   State Homes Program Application for Veterans Care Medical Certification ,   State Home report and Statement of Federal Aid Claimed ,   Request for Prescription Drugs from an Eligible Veteran in a State Home ,   State Home Inspection Staffing Profile

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ICR Summary of Burden

table that charts list 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	47,838	47,838	0	0	0	0
Annual Time Burden (Hours)	15,550	15,550	0	0	0	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,054,682

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 10/22/2012

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