Form 10-0430 APPLICATION FOR ASSISTANCE FOR HIRING AND RETAINING NURS

OMB Number: 2900-0709
Estimated Burden: 120 minutes
OMB EXP Date: XX/XXXX

APPLICATION FOR ASSISTANCE
FOR HIRING AND RETAINING NURSES AT STATE HOMES
1. NAME OF STATE HOME
A. STREET ADDRESS
C. STATE

B. CITY

D. ZIP CODE

E. PHONE

AL

2. NAME OF STATE REPRESENTATIVE (OFFICIAL DESIGNATED IN ACCORDANCE
WITH STATE AUTHORITY WITH RESPONSIBILITY FOR MATTERS RELATING TO PAYMENTS
UNDER 38 CFR PART 53) - INCLUDE COPY OF DELEGATION OF AUTHORITY:

A. PHONE

B. FAX

C. EMAIL

B. FAX

C. EMAIL

3. STATE HOME ADMINISTRATOR
A. PHONE

4. CHECK THE PROGRAM(S) FOR WHICH THE FACILITY RECEIVES PER DIEM PAYMENTS
DOMICILIARY

NURSING HOME

HOSPITAL

ADULT DAY HEALTH

5. DESCRIBE AND DOCUMENT NURSING SHORTAGE (MUST BE DOCUMENTED BY CREDIBLE EVIDENCE, SUCH AS STATE
HOME RECORDS ESTABLISHING VACANCIES OR STATE HOME RECORDS SUPPORTING THE NEED TO UTILIZE OVERTIME) ATTACH
DOCUMENTATION
6. DESCRIBE THE EMPLOYEE INCENTIVE SCHOLARSHIP PROGRAM OR OTHER EMPLOYEE INCENTIVE
PROGRAM FOR WHICH PAYMENT IS SOUGHT; EXPLAIN THE COST OF THE PROGRAM. ATTACH DOCUMENTATION
7. AMOUNT APPLIED FOR (NOT TO EXCEED 2 PERCENT OF THE AMOUNT OF THE TOTAL PER DIEM PAYMENTS
ESTIMATED BY VA TO BE MADE TO THE STATE HOME DURING THE FISCAL YEAR FOR WHICH PAYMENT WOULD BE
MADE FOR ADULT DAY HEALTH CARE, DOMICILIARY CARE, HOSPITAL CARE, AND NURSING HOME CARE)

8. DESCRIBE AVAILABILITY OF MATCHING FUNDS (AT LEAST 50% OF THE FUNDING FOR THE EMPLOYEE
INCENTIVE PROGRAM MUST BE FROM FUNDS NOT PROVIDED BY VA):
a. ATTACH A LETTER TO VA FROM AN AUTHORIZED STATE BUDGET OFFICIAL CERTIFYING THAT THE STATE FUNDS ARE, OR WILL BE,
AVAILABLE FOR THE EMPLOYEE INCENTIVE PROGRAM, SO THAT IF VA AWARDS PAYMENT, THE EMPLOYEE INCENTIVE PROGRAM MAY
PROCEED WITHOUT FURTHER STATE ACTION TO MAKE SUCH FUNDS AVAILABLE (SUCH AS FURTHER ACTION TO ISSUE BONDS).
b. IF THE CERTIFICATION IS BASED ON AN ACT AUTHORIZING FUNDS FOR THE EMPLOYEE INCENTIVE PROGRAM, ALSO ATTACH A
COPY OF THE ACT.

9. DESCRIBE WHAT MEASURES YOU WOULD TAKE TO ENSURE THAT AN INDIVIDUAL RECEIVING EMPLOYEE
INCENTIVE BENEFITS WORKS AT THE STATE HOME AS A NURSE FOR A PERIOD COMMENSURATE WITH THE
BENEFITS PROVIDED. ATTACH DOCUMENTATION
10. DESCRIBE HOW THE EMPLOYEE INCENTIVE PROGRAM WOULD ELIMINATE THE NURSING SHORTAGE AT
THE STATE HOME AND HOW LONG IT WOULD TAKE TO DO THIS. ATTACH DOCUMENTATION
11. HAS THE STATE HOME RECEIVED A REFUND PAYMENT MADE BY AN EMPLOYEE IN BREACH OF THE
TERMS OF AN AGREEMENT FOR EMPLOYEE ASSISTANCE THAT USED FUNDS UNDER THIS PROGRAM?
YES

NO

IF YES, DESCRIBE THE CIRCUMSTANCES.

ATTACH DOCUMENTATION

12. IF YES IN 11, HAS THE REFUND PAYMENT BEEN RETURNED TO THE STATE HOME'S INCENTIVE PROGRAM
YES
NO
ACCOUNT AND CREDITED AS A NON-FEDERAL FUNDING SOURCE?
15. DATE

13. Signature of State Representative
VA FORM
FEB 2014

10-0430

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APPLICATION FOR ASSISTANCE FOR HIRING AND RETAINING NURSES AT STATE HOMES
FOR VA USE ONLY
1. VA MEDICAL CENTER OF
JURISDICTION FOR STATE HOME
2. MAXIMUM AMOUNT FOR WHICH THE STATE HOME IS ELIGIBLE

SUBMIT APPLICATION WITH SUPPORTING DOCUMENTATION TO:
DEPARTMENT OF VETERANS AFFAIRS
CHIEF CONSULTANT
GERIATRICS AND EXTENDED CARE (114)
810 VERMONT AVENUE, N.W.
WASHINGTON DC 20420
The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to
respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who complete this form will average 120 minutes. This includes the time it will take to read instructions, gather the necessary facts
and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information
is used to authorize the expenditure of funds to assist State Veterans Homes in the hiring and retention of nurses and the reduction of
nursing shortages in State homes. Although this information is voluntary, failure to provide it will delay or prevent our approval of
your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may
be sent to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR
APPLICATION TO THIS ADDRESS.

VA FORM
FEB 2014

10-0430

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