Fillable Printable VA Form 10-0430

VA Form 10-0430

12. IF YES IN 11, HAS THE REFUND PAYMENT BEEN RETURNED TO THE STATE HOME'S INCENTIVE PROGRAM

ACCOUNT AND CREDITED AS A NON-FEDERAL FUNDING SOURCE?

11. HAS THE STATE HOME RECEIVED A REFUND PAYMENT MADE BY AN EMPLOYEE IN BREACH OF THE

TERMS OF AN AGREEMENT FOR EMPLOYEE ASSISTANCE THAT USED FUNDS UNDER THIS PROGRAM?

IF YES, DESCRIBE THE CIRCUMSTANCES.ATTACH DOCUMENTATION

4. CHECK THE PROGRAM(S) FOR WHICH THE FACILITY RECEIVES PER DIEM PAYMENTS

2. NAME OF STATE REPRESENTATIVE (OFFICIAL DESIGNATED IN ACCORDANCE

WITHSTATE AUTHORITY WITH RESPONSIBILITY FOR MATTERS RELATING TO PAYMENTS

UNDER 38 CFR PART 53) - INCLUDE COPY OF DELEGATION OF AUTHORITY:

A. PHONE

APPLICATION FOR ASSISTANCE

FOR HIRING AND RETAINING NURSES AT STATE HOMES

OMB Number: 2900-0709

Estimated Burden: 120 minutes

C. STATE

B. FAX C. EMAIL

1. NAME OF STATE HOME

3. STATE HOME ADMINISTRATOR

C. EMAIL

B. FAXA. PHONE

DOMICILIARYNURSING HOMEHOSPITALADULT DAY HEALTH

D. ZIP CODEB. CITY

A. STREET ADDRESS

E. PHONE

5. DESCRIBE AND DOCUMENT NURSING SHORTAGE (MUST BE DOCUMENTED BY CREDIBLE EVIDENCE, SUCH AS STATE

HOME RECORDS ESTABLISHING VACANCIES OR STATE HOME RECORDS SUPPORTING THE NEED TO UTILIZE OVERTIME)

ATTACH

DOCUMENTATION

6. DESCRIBE THE EMPLOYEE INCENTIVE SCHOLARSHIP PROGRAM OR OTHER EMPLOYEE INCENTIVE

PROGRAM FOR WHICH PAYMENT IS SOUGHT; EXPLAIN THE COST OF THE PROGRAM. ATTACH DOCUMENTATION

7. AMOUNT APPLIED FOR (NOT TO EXCEED 2 PERCENT OF THE AMOUNT OF THE TOTAL PER DIEM PAYMENTS

ESTIMATED BY VA TO BE MADE TO THE STATE HOME DURING THE FISCAL YEAR FOR WHICH PAYMENT WOULD BE

MADE FOR ADULT DAY HEALTH CARE, DOMICILIARY CARE, HOSPITAL CARE, AND NURSING HOME CARE)

8. DESCRIBE AVAILABILITY OF MATCHING FUNDS (AT LEAST 50% OF THE FUNDING FOR THE EMPLOYEE

INCENTIVE PROGRAM MUST BE FROM FUNDS NOT PROVIDED BY VA):

a. ATTACH A LETTER TO VA FROM AN AUTHORIZED STATE BUDGET OFFICIAL CERTIFYING THAT THE STATE FUNDS ARE, OR WILL BE,

AVAILABLE FOR THE EMPLOYEE INCENTIVE PROGRAM, SO THAT IF VA AWARDS PAYMENT, THE EMPLOYEE INCENTIVE PROGRAM MAY

PROCEED WITHOUT FURTHER STATE ACTION TO MAKE SUCH FUNDS AVAILABLE (SUCH AS FURTHER ACTION TO ISSUE BONDS).

b. IF THE CERTIFICATION IS BASED ON AN ACT AUTHORIZING FUNDS FOR THE EMPLOYEE INCENTIVE PROGRAM, ALSO ATTACH A

COPY OF THE ACT.

9. DESCRIBE WHAT MEASURES YOU WOULD TAKE TO ENSURE THAT AN INDIVIDUAL RECEIVING EMPLOYEE

INCENTIVE BENEFITS WORKS AT THE STATE HOME AS A NURSE FOR A PERIOD COMMENSURATE WITH THE

BENEFITS PROVIDED. ATTACH DOCUMENTATION

10. DESCRIBE HOW THE EMPLOYEE INCENTIVE PROGRAM WOULD ELIMINATE THE NURSING SHORTAGE AT

THE STATE HOME AND HOW LONG IT WOULD TAKE TO DO THIS. ATTACH DOCUMENTATION

NOYES

13. SIGNATURE OF STATE REPRESENTATIVE(Sign in ink)

VA FORM

SEP 2007

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10-0430

14. DATE

APPLICATION FOR ASSISTANCE FOR HIRING AND RETAINING NURSES AT STATE HOMES

FOR VA USE ONLY

1. VA MEDICAL CENTER OF

JURISDICTION FOR STATE HOME

2. MAXIMUM AMOUNT FOR WHICH THE STATE HOME IS ELIGIBLE

SUBMIT APPLICATION WITH SUPPORTING DOCUMENTATION TO:

DEPARTMENT OF VETERANS AFFAIRS

CHIEF CONSULTANT

GERIATRICS AND EXTENDED CARE (114)

810 VERMONT AVENUE, N.W.

WASHINGTON DC 20420

The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance

requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to

respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals

who complete this form will average 120 minutes. This includes the time it will take to read instructions, gather the necessary facts

and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This

information is used to authorize the expenditure of funds to assist State Veterans Homes in the hiring and retention of nurses and the

reduction of nursing shortages in State homes. Although this information is voluntary, failure to provide it will delay or prevent our

approval of your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the

burden may be sent to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT

SEND YOUR APPLICATION TO THIS ADDRESS.

VA FORM

SEP 2007

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10-0430