State Veterans Home Construction Grant Program

A10. Financial plan for 3 years of opeations

Guidance: Checklist Item A.11. Five Year Capital Plan

The grant applicant must submit a financial plan for state facility's first three years of operation following construction. The Program will accept the grant applicant’s preferred format for its financial plan. Please note that the financial plan is not the same as the applicant’s five-year capital plan for state's entire state home program.

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A11. Documentation Fully Occupied

The state must submit documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully occupied. Note that this is a template, and you are free to adapt as needed or submit supplemental documentation to meet this requirement. Delete any instructions that are italicized once updated. Submit as PDF.

February 10, 2019 (Insert date)

Anna Gaug

Program Manager

U.S. Department of Veterans Affairs

State Home Construction Grant Program (10NA5)

810 Vermont Avenue NW

Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug,

This document is to fulfill checklist item A.8. and certifies that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully occupied. Reference supporting documentation/demographic information.

All correspondence in regards to insert project description may be directed to insert full name of authorized state representative who can be reached at insert telephone number.

Sincerely,

Insert signature

Insert signature block

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A12. Documentation Occupancy Rate

The state must submit the 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. Note that this is a template, and you are free to adapt as needed or submit supplemental documentation to meet this requirement. Delete any instructions that are italicized once updated. Submit as PDF.

February 10, 2019 (Insert date)

Anna Gaug

Program Manager

U.S. Department of Veterans Affairs

State Home Construction Grant Program (10NA5)

810 Vermont Avenue NW

Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug,

This document is to fulfill checklist item A.12. and certifies 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 this initial application.

Sincerely,

Insert signature

Insert signature block

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A13. Documentation Travel Distance

** 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. Note that this is a template, and you are free to adapt as needed or submit supplemental documentation to meet this requirement. Delete any instructions that are italicized once updated. Submit as PDF.**

February 10, 2019 (Insert date)

Anna Gaug

Program Manager

U.S. Department of Veterans Affairs

State Home Construction Grant Program (10NA5)

810 Vermont Avenue NW

Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug,

This document is to fulfill checklist item A.13 and certifies that this application does not exceed the maximum number of state home beds as defined in 38 CFR 59.40.

If the application does 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.

Sincerely,

Insert signature

Insert signature block

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> Download DOC file: TEMPLATE Project Scope.doc

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A1B. SF424 Form

OMB Number: 4040-0004
Expiration Date: 10/31/2019
Application for Federal Assistance SF-424
1. Type of Submission: 2. Type of Application: * If Revision, select appropriate letter(s):
Preapplication New
Application Continuation * Other (Specify):
Changed/Corrected Application Revision
* 3. Date Received: 4. Applicant Identifier:
5a. Federal Entity Identifier: 5b. Federal Award Identifier:
State Use Only:
6. Date Received by State: 7. State Application Identifier:
8. APPLICANT INFORMATION:
* a. Legal Name:
b. Employer/Taxpayer Identification Number (EIN/TIN): c. Organizational DUNS:
d. Address:
* Street1:
Street2:
* City:
County/Parish:
* State:
Province:
* Country:
* Zip / Postal Code:
e. Organizational Unit:
Department Name: Division Name:
f. Name and contact information of person to be contacted on matters involving this application:
Prefix: * First Name:
Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:
* Telephone Number: Fax Number:
* Email:

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Application for Federal Assistance SF-424
* 9. Type of Applicant 1: Select Applicant Type:
Type of Applicant 2: Select Applicant Type:
Type of Applicant 3: Select Applicant Type:
* Other (specify):
* 10. Name of Federal Agency:
11. Catalog of Federal Domestic Assistance Number:
CFDA Title:
* 12. Funding Opportunity Number:
* Title:
13. Competition Identification Number:
Title:
14. Areas Affected by Project (Cities, Counties, States, etc.):
* 15. Descriptive Title of Applicant's Project:
Attach supporting documents as specified in agency instructions.

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Application for Federal Assistance SF-424
16. Congressional Districts Of:
a. Applicant b. Program/Project
Attach an additional list of Program/Project Congressional Districts if needed.
17. Proposed Project:
a. Start Date: b. End Date:
18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL
* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?
a. This application was made available to the State under the Executive Order 12372 Process for review on .
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)
Yes No
If "Yes", provide explanation and attach
21. By signing this application, I certify (1) to the statements contained in the list of certifications* and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)
** I AGREE
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.
Authorized Representative:
Prefix: * First Name:
Middle Name:
* Last Name:
Suffix:
* Title:
* Telephone Number: Fax Number:
* Email:
Signature of Authorized Representative: Date Signed:

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A1C. SF424D Form

ASSURANCES - CONSTRUCTION PROGRAMS OMB Number: 4040-0009
Expiration Date: 01/31/2019
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0042), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
NOTE:
Awarding Agency. Further, certain Federal assistance awarding agencies may require applicants to certify to additional
assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant:, I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, 8. Will comply with the Intergovernmental Personnel Act
and the institutional, managerial and financial capability of 1970 (42 U.S.C. §§4728-4763) relating to prescribed
(including funds sufficient to pay the non-Federal share standards of merit systems for programs funded
of project costs) to ensure proper planning, under one of the 19 statutes or regulations specified in
management and completion of project described in Appendix A of OPM's Standards for a Merit System of
this application. Personnel Administration (5 C.F.R. 900, Subpart F).
2. Will give the awarding agency, the Comptroller General 9. Will comply with the Lead-Based Paint Poisoning
of the United States and, if appropriate, the State, Prevention Act (42 U.S.C. §§4801 et seq.) which
the right to examine all records, books, papers, or prohibits the use of lead-based paint in construction or
documents related to the assistance; and will establish rehabilitation of residence structures.
a proper accounting system in accordance with
10. Will comply with all Federal statutes relating to non-
generally accepted accounting standards or agency
discrimination. These include but are not limited to: (a)
directives.
Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
3. Will not dispose of, modify the use of, or change the which prohibits discrimination on the basis of race,
terms of the real property title or other interest in the color or national origin; (b) Title IX of the Education
site and facilities without permission and instructions Amendments of 1972, as amended (20 U.S.C. §§1681
from the awarding agency. Will record the Federal 1683, and 1685-1686), which prohibits discrimination
awarding agency directives and will include a covenant on the basis of sex; (c) Section 504 of the
in the title of real property acquired in whole or in part Rehabilitation Act of 1973, as amended (29) U.S.C.
with Federal assistance funds to assure non- §794), which prohibits discrimination on the basis of
discrimination during the useful life of the project. handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. §§6101-6107), which prohibits
4. Will comply with the requirements of the assistance
discrimination on the basis of age; (e) the Drug Abuse
awarding agency with regard to the drafting, review and
Office and Treatment Act of 1972 (P.L. 92-255), as
approval of construction plans and specifications.
amended relating to nondiscrimination on the basis of
5. Will provide and maintain competent and adequate drug abuse; (f) the Comprehensive Alcohol Abuse and
engineering supervision at the construction site to Alcoholism Prevention, Treatment and Rehabilitation
ensure that the complete work conforms with the Act of 1970 (P.L. 91-616), as amended, relating to
approved plans and specifications and will furnish nondiscrimination on the basis of alcohol abuse or
progressive reports and such other information as may be alcoholism; (g) §§523 and 527 of the Public Health
required by the assistance awarding agency or State. Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee
3), as amended, relating to confidentiality of alcohol
6. Will initiate and complete the work within the applicable and drug abuse patient records; (h) Title VIII of the
time frame after receipt of approval of the awarding agency. Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
7. Will establish safeguards to prohibit employees from
rental or financing of housing; (i) any other
using their positions for a purpose that constitutes or
nondiscrimination provisions in the specific statue(s)
presents the appearance of personal or organizational
under which application for Federal assistance is being
conflict of interest, or personal gain.
made; and (j) the requirements of any other
nondiscrimination statue(s) which may apply to the
application.
Previous Edition Usable Authorized for Local Reproduction Standard Form 424D (Rev. 7-97)
Prescribed by OMB Circular A-102

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11. Will comply, or has already complied, with the Federal actions to State (Clean Air) implementation
requirements of Titles II and III of the Uniform Relocation Plans under Section 176(c) of the Clean Air Act of
Assistance and Real Property Acquisition Policies Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g)
1970 (P.L. 91-646) which provide for fair and equitable protection of underground sources of drinking water
treatment of persons displaced or whose property is under the Safe Drinking Water Act of 1974, as
acquired as a result of Federal and federally-assisted amended (P.L. 93-523); and, (h) protection of
programs. These requirements apply to all interests in real endangered species under the Endangered Species
property acquired for project purposes regardless of Act of 1973, as amended (P.L. 93-205).
Federal participation in purchases.
16. Will comply with the Wild and Scenic Rivers Act of
12. Will comply with the provisions of the Hatch Act (5 U.S.C.
1968 (16 U.S.C. §§1271 et seq.) related to protecting
§§1501-1508 and 7324-7328) which limit the political
components or potential components of the national
activities of employees whose principal employment
wild and scenic rivers system.
activities are funded in whole or in part with Federal funds.
17. Will assist the awarding agency in assuring compliance
13. Will comply, as applicable, with the provisions of the Davis-
with Section 106 of the National Historic Preservation
Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
Act of 1966, as amended (16 U.S.C. §470), EO 11593
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
(identification and protection of historic properties), and
Work Hours and Safety Standards Act (40 U.S.C. §§327-
the Archaeological and Historic Preservation Act of
333) regarding labor standards for federally-assisted
1974 (16 U.S.C. §§469a-1 et seq).
construction subagreements.
18. Will cause to be performed the required financial and
14. Will comply with flood insurance purchase requirements of
compliance audits in accordance with the Single Audit
Section 102(a) of the Flood Disaster Protection Act of 1973
Act Amendments of 1996 and OMB Circular No. A-133,
(P.L. 93-234) which requires recipients in a special flood
"Audits of States, Local Governments, and Non-Profit
hazard area to participate in the program and to purchase
Organizations."
flood insurance if the total cost of insurable construction
and acquisition is $10,000 or more. 19. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
15. Will comply with environmental standards which may be
governing this program.
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National 20. Will comply with the requirements of Section 106(g) of
Environmental Policy Act of 1969 (P.L. 91- the Trafficking Victims Protection Act (TVPA) of 2000, as
190) and Executive Order (EO) 11514; (b) notification amended (22 U.S.C. 7104) which prohibits grant award
of violating facilities pursuant to EO 11738; (c) recipients or a sub-recipient from (1) Engaging in severe
protection of wetlands pursuant to EO 11990; (d) forms of trafficking in persons during the period of time
evaluation of flood hazards in floodplains in accordance that the award is in effect (2) Procuring a commercial
with EO 11988; (e) assurance of project consistency sex act during the period of time that the award is in
with the approved State management program effect or (3) Using forced labor in the performance of the
developed under the Coastal Zone Management Act of award or subawards under the award.
1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
APPLICANT ORGANIZATION DATE SUBMITTED
SF-424D (Rev. 7-97) Back

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A1D. SF424C Form

OMB Number: 4040-0008
Expiration Date: 01/31/2019
BUDGET INFORMATION - Construction Programs
NOTE: Certain Federal assistance programs require additional computations to arrive at the Federal share of project costs eligible for participation. If such is the case, you will be notified.
a. Total Cost b. Costs Not Allowable c. Total Allowable Costs
COST CLASSIFICATION
for Participation (Columns a-b)
1. Administrative and legal expenses
$ $ $
2. Land, structures, rights-of-way, appraisals, etc. $ $ $
3. Relocation expenses and payments $ $ $
4. Architectural and engineering fees $ $ $
5. Other architectural and engineering fees $ $ $
6. Project inspection fees $ $ $
7. Site work $ $ $
8. Demolition and removal $ $ $
9. Construction $ $ $
10. Equipment $ $ $
11. Miscellaneous
$ $ $
12. SUBTOTAL (sum of lines 1-11) $ $ $
13. Contingencies $ $ $
14. SUBTOTAL $ $ $
15. Project (program) income $ $ $
16. TOTAL PROJECT COSTS (subtract #15 from #14) $ $ $
FEDERAL FUNDING
17. Federal assistance requested, calculate as follows:
(Consult Federal agency for Federal percentage share.) Enter eligible costs from line 16c Multiply X % $
Enter the resulting Federal share.

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> Download XLSX file: TEMPLATE Budget Justification and Construction Cost Worksheet.xlsx

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A2. Governor's designation of authorized state official and contact person

Please ensure the Governor’s Designation Letter is on official state letterhead and signed by the appropriate party. Note that this is a template, and you are free to adapt as needed. Delete any instructions that are italicized once updated. Submit as PDF.

February 10, 2019 (Insert date)

Anna Gaug

Program Manager

U.S. Department of Veterans Affairs

State Home Construction Grant Program (10NA5)

810 Vermont Avenue NW

Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug,

This is to inform you that insert full name of authorized state representative for the insert name of home is hereby designated as the official and contact person to act and be responsible in all matters relating to the State Home Construction Grant Program.

All correspondence in regards to insert description may be directed to insert full name of authorized state representative who can be reached at insert telephone number.

Sincerely,

Insert signature

Insert signature block

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A3. Needs Assessment

Note that this is a template, and you are free to adapt as needed. The needs assessment must address items (a-h) as outlined in VA Form 10-0388-1 if the grant application is New Construction or Bed Replacement. Renovation and Life Safety projects do not need to address (a-h) but must include the reason for the project and the scope of the project. The scope of the project listed here should mirror the scope of the project listed in A.1. Project Abstract. Delete any instructions that are italicized once updated. Submit as PDF.

Checklist Item A.3. Needs Assessment

Project Title and/or Description

Location (City or County, State)

Adding or replacing nursing home or domiciliary beds

• Demographic characteristics of the veteran population of the proposed catchments area

• If great travel distances (over two hours) are imposed on veterans and their families, availability of beds

• Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year

• 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

a) Reason for the project

b) Scope of the project

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A4. State Clearinghouse

If the state participates in Executive Order 12372, submit any comments or recommendations made by the appropriate state clearing house pursuant to policies outlined in Executive Order 12372, intergovernmental review of federal programs. Reference this list for additional information https://www.whitehouse.gov/wp-content/uploads/2017/11/SPOC-Feb.-2018.pdf

If the state has no clearinghouse, the designated authorized state representative must certify compliance with this executive order. Note that this is a template, and you are free to adapt as needed. Delete any instructions that are italicized once updated. Submit as PDF.

If the state does NOT participate, use this template.

February 10, 2019 (Insert date)

Anna Gaug

Program Manager

U.S. Department of Veterans Affairs

State Home Construction Grant Program (10NA5)

810 Vermont Avenue NW

Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug,

This is to inform you that insert state does not have a state clearinghouse or participate in intergovernmental review as outlined in E.O. 12372. Insert full name of authorized state representative for the insert name of home is hereby designated as the official and contact person to act and be responsible in all matters relating to the State Home Construction Grant Program.

All correspondence in regards to insert project description may be directed to insert full name of authorized state representative who can be reached at insert telephone number.

Sincerely,

Insert signature

Insert signature block

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A5. Schematics

Guidance: Checklist Item A.5. Schematics

Schematics are required regardless of the type of work being conducted and should give Program Staff a better understanding of the affected areas during construction or renovations.

Schematics can be 8x11 drawings showing the area of work or design concept for new construction or bed replacement. Schematics are to be submitted prior to the submission of 35% design drawings (DD) and 100% construction drawings (CD), which are submitted later in the lifecycle of the grant application.

Below are examples of just a few non-traditional renovation and safety types of work.

Mold remediation project – schematics should include where the mold problem is concentrated; what facility and areas within the facility are affected; documentation of mold problem; A/E firm’s assessment; plans of affected areas with clear notations of how the remediation will be implemented.

EMR project – schematics should include applicable contractor deliverables; system and business requirements documentation; process flows; technical documentation; project timelines

Generator project – schematics should include location of generator; boiler, switchgear, warehouse supply information if available; feasibility study if available.

For more information on VA guidelines relating to design, please visit https://www.cfm.va.gov/til/dGuide.asp and explore information that may be relevant to your scope of work. Remember to reference Drawings Submittal after your initial application is submitted in Grants.gov and you are preparing to submit 35% DD and/or 100% CD.

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A6. Signed initial application certification (VA Form 10-0388-1)

OMB Number: 2900-0661
Estimated Burden: 6 hours
DOCUMENTS AND INFORMATION
REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS
INITIAL APPLICATION
An initial application should be submitted to the State Home Construction Grant Program (SHCGP) by April 15, if the state
wishes consideration of an initial application for placement on the priority list for the next fiscal year.
PROJECT DESCRIPTION
PROJECT LOCATION FAI NUMBER
SECTION I - STANDARD FORMS
1. SF 424, APPLICATION
2. SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS.
a. Equipment cost estimate is not to exceed 10 percent of the construction costs; and
b. Contingency cost estimate is not to exceed 5 percent of the estimated cost of project for new construction or 8
percent for remodeling projects).
3. SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS.
SECTION II - DOCUMENTATION REQUIREMENTS
1. Description and scope of the project, including project site description and location.
2. Governor's letter or a letter from the agency authorized by the governor with program oversight designating the state representative
and information that will permit VA to contact the state representative. The state representative must notify the SHCGP,
immediately of any changes in who the state representative is and how to reach him or her.
3. Needs Assessment (Must include the following criteria):
ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:
a. Demographic characteristics of the veteran population of the proposed catchments area.
b. If great travel distances (over two hours) are imposed on veterans and their families, availability of beds.
c. Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.
d. Number of state nursing home and domiciliary beds and the occupancy rate of those facilities for the previous fiscal year.
e. 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.
f. Waiting lists for existing state home programs.
g. Plans for acute medical care/emergency care services as may be required by the state home residents.
h. Availability of qualified medical care personnel to staff the proposed facility.
NOT ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:
a. Reason for the project.
b. The scope of the project.
4. 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.
VA FORM 10-0388-1 PAGE 1 OF 2
JUL 2013

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SECTION II CONTINUED- DOCUMENTATION REQUIREMENTS
5. State application identifier number (if applicable).
6. Schematic drawings for the proposed project.
7. Information on VA Form 10-0388-3 and 10-0388-4 should correspond with charts in 140 and 160. Also see the VA community
Living Center Design Guide.
SECTION III - ADDITIONAL DOCUMENTATION FOR BED PROJECTS
8. Documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that
are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully occupied.
9. Five-year capital plan for state's entire state home program, including the proposed project.
10. Financial plan for state facility's first three years of operation following construction.
11. 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.
12. 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.
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
SIGNATURE DATE (mm/dd/yyyy)
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 this
Act. The public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are
not required to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections
8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to
meet VA requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to
authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM 10-0388-1 PAGE 2 OF 2
JUL 2013

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A7. Safety Program Guidance

State Home Construction Grant Program
Safety Grant Applications and Safety Citation Plans
I. SAFETY and SECURITY GRANT APPLICATIONS
Formal safety citations serve as the basis for requesting a VA grant (65% state matching funds)
for correction. VA will require specific information to determine if the project meets the
requirements of a safety project. The total cost of each portion of the safety project (fire alarm,
nurse call, security cameras, etc.) must be provided.
38CFR59.50(a)(1)(i) states: “An application for a life or safety project, which means a
project to remedy a condition, or conditions, at an existing facility that have been cited
as threatening to the lives or safety of one or more of the residents or program
participants in the facility by a VA safety office, VA engineering office, or other VA
office with responsibility for life and safety inspections; a State or local government
agency (including a Fire Marshal); or an accrediting institution (including the Joint
Commission on Accreditation of Healthcare Organizations).”
All Safety and Security applications need to include documentation of hazard or
certification that the project addresses threat to life and safety with the initial application.
• Submit cited document or report with corrective action; or
• Contact local VAMC for inspection (phone or visit); or,
• Contact grant office to make assignment.
All states should contact the State Home Construction Program Office to discuss
the safety application prior to submitting into grants.gov.
All Safety and Security projects have priority for FY funding. These projects must
meet specific project cost requirements to qualify for safety project ranking on the VA
Priority List.
To be listed in the Safety and Security sub-priority (1.1.A-H):
• Safety projects >$400,000 must be submitted without non-safety
project work.
• Safety projects <$400,000 may add non-safety work to meet the
minimum $400k. The majority of the project cost must be safety.

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Safety work not qualified for Safety and Security sub-priority (1.1.A-H):
• Projects with a safety project cost >$400,000 and that represent the
largest portion of the project cost will be prioritized based on the
component with the next largest cost. (States will be asked to split
the project into two applications).
Individual safety projects can be grouped across multiple facilities into
one project to obtain a total cost of >$400k.
State Matching Funds should be provided for all safety projects.
II. SAFETY CITATION PLANS
All state grant applications (funded and unfunded) should submit a safety citation plan that lists
all OPEN SAFETY CITATIONS for all state home facilities. The plan should list the corrective
action and completion date to address the citation.
 The safety citation plan is not a listing of the state safety grant applications.
 The VA does not require that a grant application be submitted for state safety citations.
 The safety citation plan is intended to assure the VA that all safety citations at state
veterans homes are being addressed.
38CFR59.50(e) states: “If any State home in a State has been cited by a VA safety
office, VA engineering office, or other VA office with responsibility for life and safety
inspections; a State or local government agency (including a Fire Marshal); or an
accrediting institution (including the Joint Commission on Accreditation of Healthcare
Organizations) for conditions that threaten the lives or safety of one or more of the
residents or program participants in the facility, the State must include in any application
submitted under § 59.20 or its updates to such application its plan to address all such
citations.”
States should submit a document (safety citation plan) that lists all safety
citations and corrective action with completion date for each state veterans
home.
Create a cover page document with the safety citation plan that lists all the state
applications (FAI#s) on the current and upcoming VA Priority List.
VA will add the state plan to all the state applications listed. If the state has no safety
citations, provide VA with a “no safety citation” letter.

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38CFR59.50(e) further states, “If VA determines that the State’s plan fails to set forth
how it will address such citations in a reasonable period of time, and then VA will
prioritize all applications of such State as follows….”
• Project with State Matching Funds States that fail to address the Safety
Citation Plan requirements will have ALL PG1 grant applications moved into sub-
priority 1.6.0, excluding projects that would be ranked 1.1.A-H (Safety) and 1.7
(New construction – limited bed need).
• Projects with no State Matching Funds States that fail to address the Safety
Citation Plan requirements have ALL PG2-8 grant applications moved into sub-
priority 7.0.
Each year, submit the cover document and the list of state home safety citations. Only one
submittal is needed for all grant applications.
List all state grant applications on the cover document, this includes:
All initial applications submitted for the upcoming VA Priority List; and
All applications on the current VA Priority List that will not be awarded or will
receive a conditional grant award.
Safety Citation Plans should be submitted to VA grant office by August 1st.

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A8. Space Program Form 10-0388-3

OMB Number 2900-0661
Estimated Burden: 2 hours
STATE HOME CONSTRUCTION GRANT PROGRAM
SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY
PROJECT DESCRIPTION
PROJECT LOCATION FAI NUMBER
This form is required for all new construction or general renovations that effect
the square footage or floor plan of an existing home. 38.CFR 59-140
SQUARE FOOTAGE
1. SUPPORT FACILITIES
PROPOSED BY
ADMINISTRATOR'S OFFICE
ASSTISTANT ADMINISTRATOR
MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT
NURSES' OFFICE AND DICTATION AREA
GENERAL ADMINISTRATION
CLERICAL STAFF
COMPUTER AREA
CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)
LOBBY/WAITING AREA
PUBLIC TOILETS (MALE, FEMALE)
PHARMACY
DIETETIC SERVICE
DINING AREA
CANTEEN, RETAIL SALES
MEDICAL SUPPORT (Each)
BARBER AND / OR BEAUTY
MAIL ROOM
JANITORS CLOSET
MULTIPURPOSE ROOM
EMPLOYEE LOCKERS
EMPLOYEE LOUNGE
EMPLOYEE TOILETS
CHAPEL
PHYSICAL THERAPY
OFFICE, IF REQUIRED
OCCUPATIONAL THERAPY
OFFICE, IF REQUIRED
LIBRARY
BUILDING MAINTENANCE STORAGE
RESIDENT STORAGE
GENERAL WAREHOUSE STORAGE (medical, dietary)
GENERAL LAUNDRY
VA FORM 10-0388-3 Page 1 of 2
JUL 2013

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SQUARE FOOTAGE
1. SUPPORT FACILITIES (Continued)
PROPOSED BY
JANITOR CLOSET
RESIDENT LAUNDRY
TRASH COLLECTION
OTHER (Justify)
2. BED UNITS
ONE: ROOMS
TWO: ROOMS
LARGE 2: ROOMS
LOUNGE AREAS:
RESIDENT QUIET ROOM
CLEAN UTILITY
SOILED UTILITY
LINEN STORAGE
GENERAL STORAGE
MEDICATION ROOM
EXAMINATION / TREATMENT ROOM
WAITING AREA
UNIT SUPPLY AND EQUIPMENT
STAFF TOILET
STRETCHER / WHEELCHAIR STORAGE
KITCHENETTE
3. BATHING AND TOILET FACILITIES
PRIVATE OR SHARED FACILITIES
FULL BATHROOM
CONGREGATE BATHING FACILITIES
TOTALS
COMPREHENSIVE SUB-TOTALS:
SUPPORT FACILITIES
BED UNITS
BATHING AND TOILET FACILITIES
GRAND TOTAL:
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
SIGNATURE DATE
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 this Act. The
public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are not required to respond to, a
collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this
information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to
rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a complete package. Your failure to
furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM 10-0388-3 Page 2 of 2
JUL 2013

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A8. Space Program Form 10-0388-4

OMB Number 2900-0661
Estimated Burden: 2 hours
STATE HOME CONSTRUCTION GRANT PROGRAM
SPACE PROGRAM ANALYSIS - ADULT DAY HEALTH CARE
PROJECT DESCRIPTION
PROJECT LOCATION FAI NUMBER
This form is required for all new construction or general renovations that effect
the square footage or floor plan of an existing home.
SQUARE FOOTAGE
1. SUPPORT FACILITIES
PROPOSED BY
ADMINISTRATOR'S OFFICE
ASSISTANT ADMINISTRATOR
MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT
NURSES' OFFICE AND DICTATION AREA
GENERAL ADMINISTRATION
CLERICAL STAFF
COMPUTER AREA
CONFERENCE ROOM (CONSULTATION AREA / IN-SERVICE TRAINING)
LOBBY/RECEIVING/WAITING AREA
PUBLIC TOILETS (MALE, FEMALE)
PARTICIPANT TOILETS (MALE, FEMALE)
DINING AREA
MEDICAL SUPPORT (Each)
JANITORS CLOSET
MULTIPURPOSE ROOM
EMPLOYEE LOCKERS
EMPLOYEE LOUNGE
EMPLOYEE TOILETS
PHYSICAL THERAPY
OFFICE, IF REQUIRED
OCCUPATIONAL THERAPY
OFFICE, IF REQUIRED
MEDICAL/DIETARY
BUILDING MAINTENANCE STORAGE
RESIDENT STORAGE
GENERAL WAREHOUSE STORAGE (medical, dietary)
GENERAL LAUNDRY
PARTICIPANT LAUNDRY
TRASH COLLECTION
PARTICIPANT QUIET ROOM
CLEAN UTILITY
SOILED UTILITY
VA FORM 10-0388-4
Page 1 of 2
JUL 2013

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SQUARE FOOTAGE
1. SUPPORT FACILITIES (Continued)
PROPOSED BY
GENERAL STORAGE
MEDICATION ROOM
EXAMINATION / TREATMENT ROOM
WAITING AREA
PROGRAM SUPPLY AND EQUIPMENT
STAFF TOILET
WHEELCHAIR STORAGE
KITCHENETTE
OTHER (Justify)
GRAND TOTAL:
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
SIGNATURE DATE
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 this Act. The public reporting burden for this collection of information is estimated to average 2 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control Number. This
collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other
documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to
rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a
complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM 10-0388-4 Page 2 of 2
JUL 2013

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A9. Five Year Capital Plan

Guidance: Checklist Item A.10. Five Year Capital Plan

The grant applicant must submit a five-year capital plan for state's entire state home program, including the proposed project. The Program will accept the grant applicant’s preferred format for its capital plan. Please note that the five year capital plan is not the same as the applicant’s financial plan for state facility's first three years of operation following construction.

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Checklist (Do not submit this - this is for reference)

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