10-0388-4 Sate Home Construction Grant Program Space Program Analy

OMB Number 2900-0661
Estimated Burden: 2 hours

STATE HOME CONSTRUCTION GRANT PROGRAM
SPACE PROGRAM ANALYSIS - ADULT DAY HEALTH CARE
PROJECT DESCRIPTION
PROJECT LOCATION

FAI NUMBER

This form is required for all new construction or general renovations that effect
the square footage or floor plan of an existing home.
1. SUPPORT FACILITIES

SQUARE FOOTAGE
PROPOSED BY

ADMINISTRATOR'S OFFICE
ASSISTANT ADMINISTRATOR
MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT
NURSES' OFFICE AND DICTATION AREA
GENERAL ADMINISTRATION
CLERICAL STAFF
COMPUTER AREA
CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)
LOBBY/RECEIVING/WAITING AREA
PUBLIC TOILETS (MALE, FEMALE)
PARTICIPANT TOILETS (MALE, FEMALE)
DINING AREA
MEDICAL SUPPORT (Each)

JANITORS CLOSET
MULTIPURPOSE ROOM
EMPLOYEE LOCKERS
EMPLOYEE LOUNGE
EMPLOYEE TOILETS
PHYSICAL THERAPY
OFFICE, IF REQUIRED
OCCUPATIONAL THERAPY
OFFICE, IF REQUIRED
MEDICAL/DIETARY
BUILDING MAINTENANCE STORAGE
RESIDENT STORAGE
GENERAL WAREHOUSE STORAGE (medical, dietary)
GENERAL LAUNDRY
PARTICIPANT LAUNDRY
TRASH COLLECTION
PARTICIPANT QUIET ROOM
CLEAN UTILITY
SOILED UTILITY
VA FORM
JUL 2013

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SQUARE FOOTAGE
PROPOSED BY

1. SUPPORT FACILITIES (Continued)
GENERAL STORAGE
MEDICATION ROOM
EXAMINATION / TREATMENT ROOM
WAITING AREA
PROGRAM SUPPLY AND EQUIPMENT
STAFF TOILET
WHEELCHAIR STORAGE
KITCHENETTE
OTHER (Justify)
GRAND TOTAL:

I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE OFFICIAL

DATE

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. The public reporting burden for this collection of information is estimated to average 2 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control Number. This
collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other
documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to
rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a
complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM
JUL 2013

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