Va Form 10 0430 PDF Details

The VA 10 0430 form plays a crucial role in addressing one of the health care system's most persistent challenges: the shortage of nursing staff in state homes. Designed as an application for financial assistance to support the hiring and retaining of nurses, this document represents a vital tool for state homes striving to provide quality care to veterans. Applicants are required to detail the nature of their nursing shortage with credible evidence, outline their employee incentive or scholarship programs aimed at resolving these shortages, and demonstrate the availability of matching funds from non-VA sources. Additionally, the form mandates a description of measures to ensure that beneficiaries of these incentive programs commit to working at the state homes for a period that matches the benefits received. It also inquires about the program's effectiveness in addressing the nursing shortage and the existence of any refund payments from employees who breached their service agreements. With the underlying goal of enhancing veterans' access to care, the form underscores the importance of strategic investments in the workforce of state-run veteran care facilities. By facilitating this process, the VA 10 0430 form embodies a key component of efforts to enhance the capacity and quality of nursing care available to those who served in the military.

QuestionAnswer
Form NameVa Form 10 0430
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOMB, attach describe payment online, 2007, va describe payment online

Form Preview Example

OMB Number: 2900-0709

Estimated Burden: 120 minutes

APPLICATION FOR ASSISTANCE

FOR HIRING AND RETAINING NURSES AT STATE HOMES

1. NAME OF STATE HOME

A. STREET ADDRESS

B. CITY

C. STATE

D. ZIP CODE

E. PHONE

2.NAME OF STATE REPRESENTATIVE (OFFICIAL DESIGNATED IN ACCORDANCE WITH STATE AUTHORITY WITH RESPONSIBILITY FOR MATTERS RELATING TO PAYMENTS UNDER 38 CFR PART 53) - INCLUDE COPY OF DELEGATION OF AUTHORITY:

A. PHONE

B. FAX

C. EMAIL

3. STATE HOME ADMINISTRATOR

 

A. PHONE

 

 

 

B. FAX

 

 

 

C. EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

DOMICILIARY

NURSING HOME

HOSPITAL

ADULT DAY HEALTH

 

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

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

YES NO

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?

YES

NO

 

 

 

 

 

 

 

 

 

 

15. DATE

13. Signature of State Representative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 10-0430

 

 

 

Page 1 of 2

SEP 2007

 

 

 

 

 

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 10-0430

Page 2 of 2

SEP 2007

 

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2. After the previous section is done, you need to insert the needed particulars in DESCRIBE THE EMPLOYEE INCENTIVE, AMOUNT APPLIED FOR NOT TO EXCEED, DESCRIBE AVAILABILITY OF MATCHING, DESCRIBE WHAT MEASURES YOU WOULD, HAS THE STATE HOME RECEIVED A, YES, YES, Signature of State Representative, and DATE so that you can proceed further.

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