Form 10-387 Medical Foster Home Caregiver Application

OMB Number: 2900-0491
Estimated Burden: 10 minutes
Expiration Date: XX/XX/20XX

MEDICAL FOSTER HOME CAREGIVER APPLICATION
VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB number. The OMB control number for this project is 2900-0491, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No.
2900-0491 in any correspondence. Do not send your completed VA Form 10-387 to this email address.
Privacy Act Notice: The information requested on this form is solicited under authority of 38 United States Code 630, and will be used to evaluate the suitability
of the home for participation in the Residential Care Program. Information is stored in a System of Records - "Community Residential Care and Medical Foster
Home Program-VA" (142VA10). It may be disclosed outside VA as permitted by law or as stated in the "Notices of Systems of VA Records," which have been
published in the Federal Register in accordance with the Privacy Act of 1974.
The VA Residential Care Program provides room, board, and limited personal care and supervision to veterans who do not require hospital or nursing home care
but because of medical or psychosocial health conditions are not able to live independently and have no suitable family resources to provide the needed care. Care is
provided at the veteran's own expense in private homes inspected by VA. The veteran receives monthly follow-up visits from VA social workers and other health
care professionals. If you wish to apply to become a Medical Foster Home caregiver in the Residential Care Home Program, please complete items 2 through 6
below.
1. VA FACILITY (For VA use Only)

2. APPLICANT INFORMATION
2A. NAME (Last, first, middle initial)

2B. TELEPHONE NUMBER

2C. DATE OF BIRTH (MM/DD/YYYY)

2D. ADDRESS (Number and Street or Rural Route, City, State and ZIP Code)

3. REFERENCES (List four references, including two neighbors)
A. NAME

B. ADDRESS

C. TELEPHONE NUMBER

B. ADDRESS

C. TELEPHONE NUMBER

(Neighbor)
(Neighbor)
4. DESIGNATED RELIEF CAREGIVERS
A. NAME

5. DOCUMENTS REQUIRED:
• State License (if applicable)
• Drivers License
6. IN MAKING APPLICATION, I AGREE TO:
a. An initial inspection of my home by a health care team from VA facility and an annual inspection thereafter.
b. Authorize VA to contact other agencies regarding the suitability of my home for residential care.
c. Comply with VA standards for residential care.
d. Accept veterans without discrimination on the basis of race, color, sex, age, religion or national origin.
e. Accept the agreed-upon monthly rate as full compensation for care given.
I understand that completing this application and initiating the certification process does not indicate that my home will be certified as a MFH. I further understand
that the VA can decide at any point prior to certification not to proceed with certification of my home. If accepted to the MFH program, I am not guaranteed
placements of Veterans in my home
7. SIGNATURE OF APPLICANT

VA FORM
OCT 2024

10-387

8. DATE (MM/DD/YYYY)