VBA-26-0967a-ARE SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion (VA Form 26-0967) & Specially Adaptive Housing Assist. Tech. Grants Criteria and Response (VA Form 26-0967a)

VBA-26-0967a-ARE

VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Respons

OMB: 2900-0903

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OMB Control Number: 2900-0821
Respondent Burden: 1 hour
Expiration Date: 11/30/2021

SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified in the VA system of records, 55VA26,
Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, and
published in the Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes collection of this
information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this
form.

IMPORTANT: Applicants for SAH Assistive technology grants must provide responses addressing the six criteria items shown below.
NOTE: If additional space is needed please attach separate sheet(s) and indicate item number with response.

(1) Describe how the new assistive technology is innovative:

VA FORM
NOV 2018

26-0967a

SUPERSEDES VA FORM 26-0967a, DEC 2015,
WHICH WILL NOT BE USED.

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SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)
(2) Explain how the new assistive technology will meet a specific, unmet need among eligible individuals:

VA FORM 26-0967a, NOV 2018

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SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)
(3) Explain how the new assistive technology is specifically designed to promote the ability of eligible individuals to live more
independently:

VA FORM 26-0967a, NOV 2018

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SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)
(4) Describe the new assistive technology's concept, size and scope:

VA FORM 26-0967a, NOV 2018

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SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)
(5) Describe the implementation plan with major milestones for bringing the new assistive technology into production and to the market.
(Note - The milestones must be meaningful and achieveable within a specific timeframe):

VA FORM 26-0967a, NOV 2018

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SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)
(6) Explain what uniquely positions the technology grant applicant in the marketplace.
(Note - This can include a focus on the characteristics such as the economic reliability of the technology grant applicant, the
technology grant applicant's status as a minority or veteran-owned business, or other characteristics that the technology grant
applicant wants to include to show how it will help protect the interests of, or further the mission of the Department of Veterans
Affairs (VA)):

VA FORM 26-0967a, NOV 2018

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File Typeapplication/pdf
File TitleScoring Criteria for SAH Assistive Technology Grants
AuthorN. Kessinger
File Modified2018-11-07
File Created2018-03-09

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