Forms for Grants to States for Construction and Acquisition of State Home Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-0338-1 Documents & Information Required for State Home Construction & Acquisition Grants-Initial Application	Form and Instruction	Modified	Available
Form 10-0388-13 DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS	Form and Instruction	Modified	Available
Form 10-0388-12 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS	Form and Instruction	Modified	Available
Form 10-0388-10 CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS	Form	Modified	Available
Form 10-0388-9 CERTIFICATION REGARDING LOBBYING	Form and Instruction	Modified	Available
Form 10-0388-8 CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS	Form and Instruction	Modified	Available
Form 10-0388-7 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS	Form and Instruction	Modified	Available
Form 10-0388-6 CERTIFICATION OF STATE MATCHING FUNDS TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST	Form	Modified	Available
Form 10-0388-5 ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION	Form	Modified	Available
Form 10-0388-4 ADULT DAY HEALTH CARE	Form	Modified	Available
Form 10-0388-3 SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY	Form	Modified	Available
Form 10-0388-2 CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT	Form and Instruction	Modified	Available
Request for Non-substantive change to VA forms 10-0388 (v2).doc	Justification for No Material/Nonsubstantive Change	Uploaded 2013-08-13	Available
10-0388-14 7-22-2013.pdf	Supplementary Document	Uploaded 2013-08-13	Available
2900-0661 justification.docx	Supporting Statement A	Uploaded 2011-07-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	Documents & Information Required for State Home Construction & Acquisition Grants-Initial Application
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form	Modified	CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	CERTIFICATION REGARDING LOBBYING
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form	Modified	CERTIFICATION OF STATE MATCHING FUNDS TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form	Modified	ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form	Modified	ADULT DAY HEALTH CARE
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form	Modified	SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Form and Instruction	Modified	CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT
28939	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Instruction	Modified

ICR Details

OMB Control No: 2900-0661	ICR Reference No: 201308-2900-029
Status: Historical Active	Previous ICR Reference No: 201104-2900-034
Agency/Subagency: VA	Agency Tracking No: 2900-0661
Title: Forms for Grants to States for Construction and Acquisition of State Home Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/19/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	01/31/2015	01/31/2015
Responses	50	0	50
Time Burden (Hours)	1,200	0	1,200
Cost Burden (Dollars)	0	0	0

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Abstract: State Governments submit to the VA information and required documentation to apply for the State Home Construction Grant Program and to certify compliance with VA requirements.

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Authorizing Statute(s): US Code: 38 USC 8133(a) Name of Law: Authorization of appropriations
   US Code: 38 USC 8135(a) Name of Law: Applications with respect to projects; payments
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AJ43	Final or interim final rulemaking	66 FR 123	06/26/2001

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 91	05/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 141	07/22/2011
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
Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	10-0388-4, 10-0388-5, 10-0388-8, 10-0388-9, 10-0388-10, 10-0388-13, 10-0338-1, 10-0388-2, 10-0388-3, 10-0388-7, 10-0388-12, 10-0388-6	CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT ,   SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY ,   ADULT DAY HEALTH CARE ,   ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION ,   CERTIFICATION OF STATE MATCHING FUNDS TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST ,   CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS ,   CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS ,   CERTIFICATION REGARDING LOBBYING ,   CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS ,   CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS ,   DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS ,   Documents & Information Required for State Home Construction & Acquisition Grants-Initial Application

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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	50	50	0	0	0	0
Annual Time Burden (Hours)	1,200	1,200	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: $0

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: 09/19/2013

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