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Agency Information Collection (Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs, and Residential Care Home Program) Activities Under OMB Review

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Information about this document as published in the Federal Register.

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Veterans Health Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.


Comments must be submitted on or before April 28, 2010.


Submit written comments on the collection of information through or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 (202) 395-7316. Please refer to “OMB Control No. 2900-0616” in any correspondence.

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Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-7485, fax (202) 273-0443 or e-mail Please refer to “OMB Control No. 2900-0616.”

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a. Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs, VA Form 10-1170.

b. Residential Care Home Program—Sponsor Application, VA Form 10-2407.

OMB Control Number: 2900-0616.

Type of Review: Extension of a currently approved collection.


a. VA Form 10-1170 is completed by community agencies wishing to provide long term care to veterans receiving VA benefits.

b. VA Form 10-2407 is an application used by a residential care facility or home that wishes to provide residential home care to veterans. It serves as the agreement between VA and the residential care home that the home will submit to an initial inspection and comply with VA requirements for residential care.

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 control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on January 15, 2010, at pages 2595-2596.

Affected Public: Business or other for-profit.

Estimated Annual Burden:

 a. VA Form 10-1170—83 hours.

 b. VA Form 10-2407—42 hours.

Estimated Average Burden per Respondent:

 a. VA Form 10-1170—10 minutes.

 b. VA Form 10-2407—5 minutes.

Frequency of Response: One time.

Estimated Number of Respondents:

 a. VA Form 10-1170—500.

 b. VA Form 10-2407—500.

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Dated: March 22, 2010.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

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[FR Doc. 2010-6845 Filed 3-26-10; 8:45 am]