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SECTION IV - NEEDS ASSESSMENT - Continued

Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal year.

Number of community-based nursing home beds and the occupancy rate at those facilities for the previous fiscal year

(must have full state certification). The state certification must authorize appropriate level(s) of care to allow veteran

placement in those facilities.

Waiting lists for existing state home programs.

Plans for acute medical care/emergency care services as may be required by the state home residents.

Availability of qualified medical care personnel to staff the proposed facility.

NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:

Reason for the project.

The scope of the project.

SECTION V - ADDITIONAL REQUIREMENTS

If a state proposes new beds that exceed the maximum number of state home beds as defined in 38 CFR 59.40, the state must

provide documentation to justify an exception on the basis of great travel distances (greater than two hours) between a significant

population center and an existing state home. The secretary will consider and approve/disapprove such justification in the

determination of the priority of the initial application.

Authorized state representative's certified statement that the list of the total number of state-operated nursing home and

domiciliary beds for veterans is the total number of such beds existing, under construction, or pending approval by VA at the time

of the initial application.

Schematic drawings for the proposed project.

Space program analysis on VA Form 10-0388-3, SPACE PROGRAM ANALYSIS-NURSING HOME AND DOMICILIARY (or VA

Form 10-0388-4, SPACE PROGRAM ANALYSIS-ADULT DAY HEALTH CARE) for the proposed project that includes a list of

each room or area and the square footage proposed. The plan should note special or unusual services or equipment. The

information on VA Form 10-0388-3 (or VA Form 10-0388-4) should correspond with the charts contained in 38 CFR 59.140 and

59.160

State application identifier number (if applicable).

DUNS Number.

Five-year capital plan for state's entire state home program, including the proposed project.

Financial plan for state facility's first three years of operation following construction.

Any comments or recommendations made by the appropriate state clearing house pursuant to policies outlined in Executive

Order 12372, intergovernmental review of federal programs (part 40 of this chapter). If the state has no clearinghouse, the

designated authorized state representative must certify compliance with this executive order.

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.

I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.

NAME OF AUTHORIZED STATE OFFICIAL

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

SIGNATURE

VA FORM

10-0388-1

PAGE 2 OF 2

MAY 2005

Va Form 10-0388-1 - Documents And Information Required For State Home Construction And Acquisition Grants Initial Application Page 2