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Get Va Form 10 3567 2015-2024

OMB No. 2900-0160 Estimated Burden: 30 minutes Exp. Date: 02/28/2019 STATE HOME INSPECTION - STAFFING PROFILE INSTRUCTIONS 1. The Staffing Profile consists of 5 Parts. 2. Complete Part I, noting numbers of operating beds, beds authorized for VA per diem payments, patient census (veterans and non-veterans), full time employee equivalents (FTEE) authorized, and FTEE available at the time of the inspection for each level of care provided by the home, i.e., nursing home, domiciliary, and/or adult.

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