Va Form 10-0430 - Application For Assistance For Hiring And Retaining Nurses At State Homes Page 2
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1
2APPLICATION 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.
10-0430
Page 2 of 2
VA FORM
SEP 2007
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