Title 38, Parts 51 and 52, State Home Program

Title 38, Parts 51 and 52, State Home Programs

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 10-0143 Title 38, Parts 51 and 52, State Home Program Form
10-0143 Department of Veterans Affairs Certification Regarding D 2900-0160 VA Form 10-0143.pdf www.va.gov/vaforms/ Form
10-0143A Statement of Assurance of Compliance with Section 504 of 2900-0160 VA Form 10-0143A.pdf www.va.gov/vaforms/ Form
10-0144 Certification Regarding Lobbying 2900-0160 VA Form 10-0144.pdf www.va.gov/vaforms/ Form
10-0144A Statement of Assurance of Compliance with Equal Opportun 2900-0160 VA Form 10-0144A.pdf www.va.gov/vaforms/ Form
10-10SH State Homes Program Application for Veterans Care Medica 10-10SH-fill.pdf www.va.gov/vaforms/ Form
10-5588 State Home report and Statement of Federal Aid Claimed 10-5588-fill.pdf www.va.gov/vaforms/ Form
10-0460 Request for Prescription Drugs from an Eligible Veteran 10-0460-fill.pdf www.va.gov/vaforms/ Form
VA Form 10-3567 State Home Inspection Staffing Profile 10-3567-fill.pdf www.va.gov/vaforms/ Form

Information Collection (IC) Details

IC Title:	Title 38, Parts 51 and 52, State Home Program	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0143	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	2900-0160 VA Form 10-0143.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0143A	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	2900-0160 VA Form 10-0143A.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0144	Certification Regarding Lobbying	2900-0160 VA Form 10-0144.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0144A	Statement of Assurance of Compliance with Equal Opportunity Laws	2900-0160 VA Form 10-0144A.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-10SH	State Homes Program Application for Veterans Care Medical Certification	10-10SH-fill.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-5588	State Home report and Statement of Federal Aid Claimed	10-5588-fill.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	10-0460	Request for Prescription Drugs from an Eligible Veteran in a State Home	10-0460-fill.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	VA Form 10-3567	State Home Inspection Staffing Profile	10-3567-fill.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45,318	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47,838	180	47,658
Annual IC Time Burden (Hours)	15,550	15	15,535
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.