Va Form 10-0388-4 - State Home Construction Grant Programadult Day Health Care Page 3
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1
2
3
4PROPOSED
TOTAL VA
3. BATHING AND TOILET FACILITIES
BY STATE
ALLOWED
VA CRITERIA
A. PRIVATE OF SHARED FACILITIES
WHEELCHAIR FACILITIES #
ROOMS X
@ =
25/FIXTURE
(50% OF TOTAL, MINIMUM COMPLIANCE WITH UFAS)
25/FIXTURE
ROOMS X
STANDARD FACILITIES #
@ =
15/FIXTURE
25/FIXTURE
@ =
FULL BATHROOM #
ROOMS X
75
25/FIXTURE
CONGREGATE BATHING FACILITIES - FIRST TUB/SHOWER
80
EACH ADDITIONAL FIXTURE #
25
UNIT SUB-TOTAL:
x
TIMES NO. OF UNITS:
x
SUB-TOTAL - ALL UNIT TOILETS
Mechanical, electrical and other engineering/utility areas, in addition to engineering workshops and circulation space, are not
NOTE 1:
included in the Space Analysis or the Percentage of Participation calculations.
All areas not shown on this form must be justified, on a programmatic medical care or state imposed regulatory basis, in order
NOTE 2:
for VA to participate in the funding of that space.
TOTALS
PROPOSED BY
TOTAL VA
VA CRITERIA
COMPREHENSIVE SUB-TOTALS
STATE
ALLOWED
SUPPORT FACILITIES - CRITERIA
SUPPORT FACILITIES - AS REQUIRED
AR
AR
BATHING AND TOILET FACILITIES
GRAND TOTALS - CRITERIA AREAS:
GRAND TOTALS - AS REQUIRED AREAS:
AR
AR
If prepared by State:
I certify that this accurately reflects the proposed Space Program Analysis for this project:
Signature
Date (mm/dd/yyyy)
COMPUTATIONS
PROPOSED BY STATE
ALLOWED BY VA
ANALYSIS
CRITERIA AREAS
+
10% DEVIATION
+
+
AS REQUIRED AREAS
TOTAL STATE PROPOSED:
TOTAL VA ALLOWED:
FORMULA FOR % OF VA PARTICIPATION:
VA ALLOWED:
x 0.65
%
=
STATE PROPOSED:
%
OFFICIAL PERCENTAGE OF VA PARTICIPATION
CERTIFIED
State Home Grant Program, Office of Facilities Management (181A), 811 Vermont Avenue, NW, Washington, D.C. 20420
Date (mm/dd/yyyy)
VA FORM
10-0388-4
Page 3 of 4
MAR 2005
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