Va Form 10 0430 – Fill Out and Use This PDF

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

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:

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