10-0338-1 Documents & Information Required for State Home Construc

OMB Number: 2900-0661
Estimated Burden: 6 hours

DOCUMENTS AND INFORMATION
REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS
INITIAL APPLICATION
An initial application should be submitted to the Chief Consultant, Geriatrics and Extended Care (114) by April 15, if the
state wishes consideration of an initial application for placement on the priority list for the next fiscal year.
PROJECT DESCRIPTION

PROJECT LOCATION

GRANT TYPE

FAI NUMBER

ACQUISITION
CONSTRUCTION

SECTION I - STANDARD FORMS

1.

SF 424, APPLICATION

2.

SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS.

3.

a.

Equipment cost estimate is not to exceed 10 percent of the construction costs; and

b.

Contingency cost estimate is not to exceed 5 percent of the estimated cost of project for new construction or 8 percent for
remodeling projects).

SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS.
SECTION II - DOCUMENTATION REQUIREMENTS

1.

Description and scope of the project, including project site description and location.

2.

Governor's letter or a letter from the agency authorized by the governor with program oversight designating the state
representative and information that will permit VA to contact the state representative. The state representative must notify the
chief consultant (114), immediately of any changes in who the state representative is and how to reach him or her.

3.

Needs Assessment (Must include the following criteria):
ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:
a.

Demographic characteristics of the veteran population of the proposed catchments area.

b.

If great travel distances (over two hours) are imposed on veterans and their families, availability of beds.

c.

Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.

d.

Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal
year.

e.

Number of community-based nursing home beds and the occupancy rate at those facilities for the previous fiscal year
(must have full state certification). The state certification must authorize appropriate level(s) of care to allow veteran
placement in those facilities.

f.

Waiting lists for existing state home programs.

g.

Plans for acute medical care/emergency care services as may be required by the state home residents.

h.

Availability of qualified medical care personnel to staff the proposed facility.

NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

4.

a.

Reason for the project.

b.

The scope of the project.

Any comments or recommendations made by the appropriate state clearing house pursuant to policies outlined in Executive
Order 12372, intergovernmental review of federal programs (part 40 of this chapter). If the state has no clearinghouse, the
designated authorized state representative must certify compliance with this executive order.

VA FORM
DEC 2010

10-0388-1

PAGE 1 OF 2

SECTION II CONTINUED- DOCUMENTATION REQUIREMENTS

5.

State application identifier number (if applicable).

6.

Schematic drawings for the proposed project.

7.

Space program analysis on VA Form 10-0388-3, SPACE PROGRAM ANALYSIS-NURSING HOME AND DOMICILIARY (or VA
Form 10-0388-4, SPACE PROGRAM ANALYSIS-ADULT DAY HEALTH CARE) for the proposed project that includes a list of
each room or area and the square footage proposed. The plan should note special or unusual services or equipment. The
information on VA Form 10-0388-3 (or VA Form 10-0388-4) should correspond with the charts contained in 38 CFR 59.140 and
59.160
SECTION III - ADDITIONAL DOCUMENTATION FOR BED PROJECTS

8.

Documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that
are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully
occupied.

9.

Five-year capital plan for state's entire state home program, including the proposed project.

10.

Financial plan for state facility's first three years of operation following construction.

11.

Authorized state representative's certified statement that the list of the total number of state-operated nursing home and
domiciliary beds for veterans is the total number of such beds existing, under construction, or pending approval by VA at the time
of the initial application.

12.

If a state proposes new beds that exceed the maximum number of state home beds as defined in 38 CFR 59.40, the state must
provide documentation to justify an exception on the basis of great travel distances (greater than two hours) between a significant
population center and an existing state home. The secretary will consider and approve/disapprove such justification in the
determination of the priority of the initial application.

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
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 (mm/dd/yyyy)

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 6 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
DEC 2010

10-0388-1

PAGE 2 OF 2