View Information Collection (IC)
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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Title 38, Parts 51 and 52, State Home Program
Agency IC Tracking Number:
2900-0160
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
38 CFR 51
38 CFR 52
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
10-0143
Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
2900-0160 VA Form 10-0143.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-0143A
Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973
2900-0160 VA Form 10-0143A.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-0144
Certification Regarding Lobbying
2900-0160 VA Form 10-0144.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-0144A
Statement of Assurance of Compliance with Equal Opportunity Laws
2900-0160 VA Form 10-0144A.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-10SH
State Homes Program Application for Veterans Care Medical Certification
10-10SH-fill.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-5588
State Home report and Statement of Federal Aid Claimed
10-5588-fill.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
10-0460
Request for Prescription Drugs from an Eligible Veteran in a State Home
10-0460-fill.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Form
VA Form 10-3567
State Home Inspection Staffing Profile
10-3567-fill.pdf
http://www.va.gov/vaforms/
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
45,318
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 New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
47,838
0
0
180
0
47,658
Annual IC Time Burden (Hours)
15,550
0
0
15
0
15,535
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
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