Form 10-381 Appointment Certification Form

OMB Control No. 2900-XXXX
Estimated Burden: 2 minutes
Expiration Date: XX/XX/20XX

VETERANS CHILD CARE ASSISTANCE PROGRAM (VCAP)
APPOINTMENT CERTIFICATION FORM
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 2 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at [email protected]. Please refer to OMB Control No. 2900-XXXX in any correspondence. Do not send your completed VA Form 10-381 to this email address.
PRIVACY ACT STATEMENT: The information requested on this form is solicited under authority of Title 38 United States Code, Sections 5701 and 7332, and will be used to assist VA in
determining your entitlement to VCAP child care services. The information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974. This
form is part of the system of records identified as 24VA19 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at
https://www.gpo.gov/privacy. Information collected will not be used for any other purpose. Your disclosure of information is voluntary; however, failure to furnish the required information
will result in our inability to provide services or process your claim. Your failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled.
1. VETERAN'S NAME (Last, First, Middle Initial)

2. VETERAN'S VA IDENTIFICATION NUMBER (or Last 4 of SSN)

3. VETERAN'S CELL PHONE NUMBER ((999) 999-9999)

4. DATE OF APPOINTMENT (MM/DD/YYYY)

5. ELIGIBLE APPOINTMENTS FOR CHILD CARE ASSISTANCE
(1) A REGULAR MENTAL HEALTH CARE APPOINTMENT.
Regular mental health care means mental health care that is provided on a recurrent basis. There is no minimum requirement for the frequency or duration of such
intervals to be considered regular mental health care.
(2) AN INTENSIVE MENTAL HEALTH APPOINTMENT.
Intensive mental health care means mental health care that is more intense in degree of treatment than routine mental health care.
(3) AN INTENSIVE HEALTH CARE APPOINTMENT.
Intensive health care means any health care provided to an eligible veteran when the presence of the child may impact the effective provision of such health care.
Examples include:
• An appointment where the presence of the child may be inappropriate, unsafe, or uncomfortable for the child or the veteran.
• An appointment where it may be difficult for the veteran to adequately supervise the child for the duration of the appointment.
THE ELIGIBLE APPOINTMENT MUST TAKE PLACE AT A VA MEDICAL FACILITY.
INELIGIBLE AAPOINTMENTS
TERTIARY CARE APPOINTMENTS ARE NOT ELIGIBLE FOR CHILD CARE ASSISTANCE. Tertiary care appointments are appointments where highly specialized health
care services are provided and may render the primary caretaker unable to promptly return to the child. Such appointments include, but are not limited to:
• Emergency room visits
• Appointments requiring sedation of the veteran
6. ELIGIBLE VETERAN
AT THE TIME OF THE ELIGIBLE APPOINTMENT LISTED ABOVE, THE VETERAN MUST BE THE PRIMARY CARETAKER OF:
(1) A CHILD CONSIDERED BY THE VETERANS BENEFITS ADMINISTRATION TO BE THE VETERAN’S DEPENDENT;
(2) A CHILD (INCLUDING A GRANDCHILD OR GREAT-GRANDCHILD) WHO IS RELATED TO THE VETERAN THROUGH BIRTH, ADOPTION, OR LEGAL
GUARDIANSHIP; OR
(3) A CHILD WHO RESIDES IN THE VETERAN'S HOUSEHOLD.

7. CERTIFICATION
I certify that I am attending one of the eligible appointments listed above and that I am the primary caretaker of the child(ren) being provided child care.

VETERAN'S PRINTED NAME

VA FORM
SEP 2024

10-381

VETERAN'S SIGNATURE

DATE SIGNED (MM/DD/YYYY)

VCAP

Page 1