Information Collection

Residential Care Home Program Sponsor Application

IC 28869 under ICR 201602-2900-040 · OMB 2900-0616.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-2407 Residential Care Home Program Sponsor Application	Form
VA Form 10-2407 Residential Care Home Program_Sponsor Application VA Form 10-2407_fill_022416.pdf vaww.va.gov/vaforms/	Form

IC Title:

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	VA Form 10-2407	Residential Care Home Program_Sponsor Application	VA Form 10-2407_fill_022416.pdf	http://vaww.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Community Placement Program-VA (65VA122)

FR Citation: 56 FR 109

Number of Respondents: 500

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	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	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.