NAME OF HOME PART III SHIFT DAY RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA EVENING NIGHT PART IV SHIFT DAY EVENING NIGHT PART V SHIFT RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA DAY RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA RN LPN NA EVENING NIGHT VA FORM MAY 1998 (RS) 10-3567 PAGE 2 NAME OF HOME DATE OF INSPECTION The Paperwork Reduction Act of 1995 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 must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. VA FORM 10-3567 PAGE 3 Department of Veterans Affairs STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal aid is claimed, except for authorized absences of 96 hours or less, and that facility management has complied with all provisions of Title VI, Public Law 88-352, entitled Civil Rights Act of The Paperwork Reduction Act of 1995 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 must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. VA FORM SEP 1998 (RS) 10-5588 PAGE 2 |