View Information Collection Request (ICR) Package

OMB Control No: 2900-0160	ICR Reference No: 198803-2900-005
Status: Historical Active	Previous ICR Reference No: 198503-2900-005
Agency/Subagency: VA	Agency Tracking No:
Title: APPLICATION FOR FURNISHING NURSING HOME CARE TO BENEFICIARIES OF THE VETERANS ADMINISTRATION
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/08/1988
	Date Received in OIRA: 03/10/1988
Terms of Clearance: THIS FORM IS APPROVED FOR A LIMITED PERIOD OF TIME. WITH THE NEXT SUBMISSION OF THIS FORM FOR OMB APPROVAL, VA MUST PROVIDE A DETAILED ITEM-BY-ITIM JUSTIFICATION FOR HOW EACH INDIVIDUAL DATA ELEMENT ON THIS FORM IS USED. VA MUST IDENTIFY ITEMS WHICH ARE USED TO MEASURE COMPLIANCE WITH HHS REGULATIONS AND HOW SUCH COMPLIANCE DETERMINATIONS ARE CONDUCTED BY VA. VA MUST SPECIFICALLY IDENTIFY EACH ITEM USED FOR PURPOSES OF CONTRACT NEGOTIATIONS AND HOW EACH SPECIFIC ITEM IS USED FOR THAT PURPOSE. VA MUST EXPLAIN WHY CERTIFICATION of compliance with HHS regulations is not sufficient for VA purposes.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/1988	10/31/1988	03/31/1988
Responses	400	0	400
Time Burden (Hours)	133	0	133
Cost Burden (Dollars)	0	0	0

Abstract: THIS FORM INDICATES A NURSING HOME'S INTEREST IN PROVIDING CARE TO VETERANS THROUGH THE COMMUNITY NURSING HOME PROGRAM. THE INFORMATION ALLOWS TH VA MEDICAL CENTER STAFF TO DETERMINE THE FACILITY (RESPONDENT) IS, IN FACT, A NURSING HOME AND IF THE STAFF OF THE NURSING HOME APPEARS TO MEET CFR 42 STANDARDS.

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
APPLICATION FOR FURNISHING NURSING HOME CARE TO BENEFICIARIES OF THE VETERANS ADMINISTRATION	10-1170

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	400	400
Annual Time Burden (Hours)	133	133
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

View ICR - OIRA Conclusion