10-0388-3 Space Program Analysis - Nursing Home & Domiciliary

OMB Number 2900-0661
Estimated Burden: 2 hours

STATE HOME CONSTRUCTION GRANT PROGRAM
SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY
PROJECT DESCRIPTION
PROJECT LOCATION

FAI NUMBER

This form is required for all new construction or general renovations that effect
the square footage or floor plan of an existing home. 38.CFR 59-140
1. SUPPORT FACILITIES

SQUARE FOOTAGE
PROPOSED BY

ADMINISTRATOR'S OFFICE
ASSTISTANT ADMINISTRATOR
MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT
NURSES' OFFICE AND DICTATION AREA
GENERAL ADMINISTRATION
CLERICAL STAFF
COMPUTER AREA
CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)
LOBBY/WAITING AREA
PUBLIC TOILETS (MALE, FEMALE)
PHARMACY
DIETETIC SERVICE
DINING AREA
CANTEEN, RETAIL SALES
MEDICAL SUPPORT (Each)

BARBER AND / OR BEAUTY
MAIL ROOM
JANITORS CLOSET
MULTIPURPOSE ROOM
EMPLOYEE LOCKERS
EMPLOYEE LOUNGE
EMPLOYEE TOILETS
CHAPEL
PHYSICAL THERAPY
OFFICE, IF REQUIRED
OCCUPATIONAL THERAPY
OFFICE, IF REQUIRED
LIBRARY
BUILDING MAINTENANCE STORAGE
RESIDENT STORAGE
GENERAL WAREHOUSE STORAGE (medical, dietary)
GENERAL LAUNDRY
VA FORM
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SQUARE FOOTAGE
PROPOSED BY

1. SUPPORT FACILITIES (Continued)
JANITOR CLOSET
RESIDENT LAUNDRY
TRASH COLLECTION
OTHER (Justify)
2. BED UNITS
ONE:

ROOMS

TWO:

ROOMS

LARGE 2:

ROOMS

LOUNGE AREAS:
RESIDENT QUIET ROOM
CLEAN UTILITY
SOILED UTILITY
LINEN STORAGE
GENERAL STORAGE
MEDICATION ROOM
EXAMINATION / TREATMENT ROOM
WAITING AREA
UNIT SUPPLY AND EQUIPMENT
STAFF TOILET
STRETCHER / WHEELCHAIR STORAGE
KITCHENETTE
3. BATHING AND TOILET FACILITIES
PRIVATE OR SHARED FACILITIES
FULL BATHROOM
CONGREGATE BATHING FACILITIES
TOTALS
COMPREHENSIVE SUB-TOTALS:
SUPPORT FACILITIES
BED UNITS
BATHING AND TOILET FACILITIES
GRAND TOTAL:

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

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 2 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
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