State Home Inspection Staffing Profile

Per Diem to States for Care of Eligible Veterans in State Homes

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0883 can be found here:

Documents and Forms

Document Name Document Type
Form 10-3567 State Home Inspection Staffing Profile Form and Instruction
10-3567 State Home Inspection Staffing Profile VA form 10-3567_Needs New OMB No and Expir Date.pdf www.va.gov/vaforms/ Form and Instruction

Information Collection (IC) Details

IC Title:	State Home Inspection Staffing Profile	Agency IC Tracking Number:	2900-NEW

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 51

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-3567	State Home Inspection Staffing Profile	VA form 10-3567_Needs New OMB No and Expir Date.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: 156	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	156	156
Annual IC Time Burden (Hours)	78	78
Annual IC Cost Burden (Dollars)	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.