Application for Residential Care Home Program Sponsor Application

Forms and Documents

Document Name	Status
Form VA Form 10-2407 Residential Care Home Program Sponsor Application Form	Modified
2900-0616 Justification_8-30-2013.doc Supporting Statement A	2013-09-04

IC Document Collections

IC ID	Document Title	Status
28869	Residential Care Home Program Sponsor Application Form	Modified

ICR Details

OMB Control No: 2900-0616	ICR Reference No: 201303-2900-003
Status: Historical Active	Previous ICR Reference No: 201001-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0616
Title: Application for Residential Care Home Program Sponsor Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/06/2013
	Date Received in OIRA: 06/27/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2013
Responses	500	0	1,000
Time Burden (Hours)	42	0	125
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 10-2407 is necessary for the residential care home to qualify to provide care to veteran patients. The form covers community providers. Community Nursing Homes (CNHs) already use the form, and the form will cover Home Health and Hospice Care agencies and community adult day health care centers.

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Authorizing Statute(s): US Code: 38 USC Section 1720 Name of Law: Transfers for nursing home care; adult day health care
   US Code: 38 USC 1730 Name of Law: Community residential care
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 56	03/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 124	06/27/2013
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Residential Care Home Program Sponsor Application	VA Form 10-2407	Residential Care Home Program_Sponsor Application

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500	1,000	0	-500	0	0
Annual Time Burden (Hours)	42	125	0	-83	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: VA Form 10-1170 served as the only signed "agreement" between some providers and the VA indicating their intent to participate in the program, comply with CMS standards, and agreeing to a price structure. This program form is no longer required and has been discontinued.

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Annual Cost to Federal Government: $2,330

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/27/2013

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