Information Collection

State Homes Program Application for Veterans Care Medical Certification

IC 237053 under ICR 202410-2900-019 · OMB 2900-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0160 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10SH State Homes Program Application for Veterans Care Medical Certification	Form and Instruction
Form 10-10SH State Homes Program Application for Veterans Care Medical Certification	Form and Instruction
10-10SH State Homes Program Application for Veterans Care Medica VA Form 10-10SH.pdf www.va.gov/vaforms/	Form and Instruction
10-10SH State Homes Program Application for Veterans Care Medica VA Form 10-10SH.pdf www.va.gov/vaforms/	Form and Instruction
10-10SH Online 10-10SH - Application for State Home Care Online 10-10SH_Screenshots_2023.docx	Form and Instruction
10-10SH Online 10-10SH - Application for State Home Care Online 10-10SH_Screenshots_2023.docx	Form and Instruction

IC Title:

State Homes Program Application for Veterans Care Medical Certification

Agency IC Tracking Number:

2900-0160

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 51 38 CFR 52

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 and Instruction	10-10SH	State Homes Program Application for Veterans Care Medical Certification	VA Form 10-10SH.pdf	http://www.va.gov/vaforms/	Yes	Yes	Fillable Fileable
Form and Instruction	10-10SH	Online 10-10SH - Application for State Home Care	Online 10-10SH_Screenshots_2023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,406

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	11,406	11,406
Annual IC Time Burden (Hours)	3,802	3,802
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.