Facility details
Date in dd/mm/yyyy, VISN number, VHA facility name and location, the facility contact person and the facility director or chief executive officer.
10-0408
VHA Fisher House Application
- Agency
- VA
- Revision
- September 2005
- Fillable fields
- 29
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0408: VHA Fisher House Application
VA Form 10-0408 is the VHA Fisher House Application of the U.S. Department of Veterans Affairs. VA's form page lists it under VHA. A Veterans Health Administration (VHA) facility uses it for a proposed Fisher House: it names the facility, its Veterans Integrated Service Network (VISN) and a facility contact person, then describes the proposed site, funding commitments, workload and temporary lodging needs.
The facility director or chief executive officer signs that they support the application, and the VISN Director signs that they recommend it. Many answers go on attachments labeled with the item number, such as "RESPONSE TO ITEM 1".
The PDF has three pages: two pages with items 1 to 18 and the signatures, and a page of Privacy Act and Paperwork Reduction Act information. It carries OMB Number 2900-0630 with an estimated burden of 10 minutes. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0408
Items 1 to 3: the proposed site
A full description of the proposed location, including lot size (the form recommends approximately one acre) and its location in relation to the VHA facility, a sketched drawing, the walking time to patient treatment buildings and any special construction issues.
Items 4 to 6: funding commitments
Yes or no commitments to fund site preparation, the full operational costs including all utilities and maintenance, and one full-time equivalent (FTE) employee to serve as the Fisher House manager.
Items 7 to 9: services and workload
Specialized medical or mental health services that support the need for a Fisher House, unique Veterans served, outpatient visits and inpatient admissions in the previous fiscal year, other workload numbers, and whether the workload justifies the need.
Items 10 to 16: area and lodging options
The catchment area and patient population, referral center status, square miles, long-distance travel, whether existing hospital space or an enhanced-use public-private venture could meet lodging needs, local hotel and motel costs and rates, and potential sponsors and support.
Items 17 and 18 and signatures
Letters of endorsement, then the signature lines for the facility director or chief executive officer and the VISN Director. Page 3 holds the Privacy Act and Paperwork Reduction Act information.
How to complete VA Form 10-0408
- 1
Fill in the facility header
Enter the date, VISN number, facility name and location, the contact person and the facility director or chief executive officer.
- 2
Describe the proposed site
Answer items 1 to 3. The form asks for a sketched drawing of the site as an attachment labeled "RESPONSE TO ITEM 1" and construction issues as "RESPONSE TO ITEM 3".
- 3
Answer the commitment and workload items
Mark yes or no for items 4 to 6, describe specialized services in item 7 and enter the previous fiscal year's workload numbers in item 8.
- 4
Describe the area and lodging options
Complete items 10 to 16 on the catchment area, travel, existing space, hotel and motel costs, sponsors and any State grants or local support.
- 5
Attach endorsement letters
Items 17 and 18 ask for attachments labeled "RESPONSE TO ITEM 17" and "RESPONSE TO ITEM 18".
- 6
Collect the signatures
The facility director or chief executive officer signs and dates the support line, and the VISN Director signs and dates the recommendation line.
Why fill Form 10-0408 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes
Submission
The form prints no mailing address or submission office. Its signature lines are for the facility director or chief executive officer and the VISN Director.
Attachments
Items 1, 3, 7, 10A, 16, 17 and 18 ask for attachments labeled "RESPONSE TO ITEM" with the item number.
Authority
The form says the information is solicited under the authority of Public Law 106-419, the Veterans Benefits and Health Care Act of 2000, codified at 38 USC 1708.
Edition
The current edition is dated SEP 2005 (R). It carries OMB Number 2900-0630 with an estimated burden of 10 minutes.
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Who uses VA Form 10-0408?
The form's fields and signature lines are for VHA facility and network leaders.
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Questions about Form 10-0408
Who completes VA Form 10-0408?
A VHA facility. The form asks for the facility's VISN number, name, location, a contact person and the facility director or chief executive officer.
Who signs it?
The facility director or chief executive officer signs that they support the application, and the VISN Director signs that they recommend it.
How large should the proposed site be?
Item 1 asks for the size of the lot and says approximately one acre is recommended. Its note says the site should ideally be accessible to patient treatment buildings.
What funding commitments does it ask about?
Items 4 to 6 ask whether the signer commits to funding site preparation, the full operational costs including utilities and maintenance, and one full-time equivalent employee as the Fisher House manager.
Which workload numbers does it ask for?
Item 8 asks for unique Veterans served, outpatient visits and inpatient admissions in the previous fiscal year, plus other relevant workload numbers.
What does the privacy notice say the form is for?
The notice on page 3 says the purpose of the form is to determine eligibility for temporary lodging while the veteran undergoes extensive treatment or procedures, and that completing it is entirely voluntary.