Form 10-0408A Temporary Housing Application

OMB Number 2900-0630
Estimated Burden 10 minutes

VHA FISHER HOUSE OR OTHER
TEMPORARY LODGING APPLICATION
1. VETERANS INTEGRATED
SERVICE NETWORK (VISN) #

3. DATE (mm/dd/yyyy)

2. NAME OF VETERANS HEALTH ADMINISTRATION (VHA) FACILITY

4. LOCATION OF VHA FACILITY

5. NAME OF FACILITY CONTACT PERSON

6. TITLE

7. TELEPHONE NUMBER

8. TYPE OF LODGING ACCOMODATION
HOPTEL (Non-utilized beds and rooms
at a VA healthcare facility)

FISHER HOUSE RESIDENCE

TEMPORARY LODGING FACILITY (Hotel, Motel)

SCHEDULED CARE FOR ELIGIBLE ACTIVE DUTY SERVICE MEMBER
9. NAME OF VETERAN

10. SOCIAL SECURITY NUMBER

11. REQUESTED LODGING FOR
SELF

12. START DATE (mm/dd/yyyy)

13. TIME

14. TYPE OF CARE

FAMILY

15. END DATE (mm/dd/yyyy)

ACCOMPANYING INDIVIDUAL
16. NAME

18. RELATIONSHIP TO THE VETERAN

17. GENDER
MALE

FEMALE

ESTIMATE FROM VETERANS HOME TO VA HEALTHCARE FACILITY
19. DISTANCE

20. TIME

21. MODE OF TRANSPORTATION (Click to choose)

22. CIRCUMSTANCES THAT MAY AFFECT TIME OF TRAVEL FROM VETERANS HOME TO VA HEALTHCARE FACILITY

25. REQUESTED DATES FOR TEMPORARY LODGING (mm/dd/yyyy)
to
VA FORM
SEP 2008

10-0408A

page 1 of 2

OMB Number 2900-0630
Estimated Burden 10 minutes

The Paperwork Reduction Act & Privacy Act Statements

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 2008

10-0408A

page 2 of 2