Part I: beds, census and FTEE
Operating beds or participant slots, authorized approvals, patient census, FTEE authorized and FTEE available, each for the total facility, ADHC, NHC and DOM.
10-3567
State Home Inspection—Staffing Profile
- Agency
- VA
- Revision
- December 2023
- Fillable fields
- 370
- Pages
- 4
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-3567: State Home Inspection, Staffing Profile
VA Form 10-3567 is the U.S. Department of Veterans Affairs State Home Inspection, Staffing Profile. It records a State Home's beds, patient census and staff for each level of care the home provides: nursing home, domiciliary and adult day health care (ADHC). The form carries the name of the home and the date of inspection, and its notice says VA will be unable to certify the home without a completed form.
The PDF has four pages. Pages 1 and 2 hold the instructions and definitions, page 3 holds Part I and Part II, and page 4 holds the nursing service staffing pattern tables in Parts III to V. The form asks for facility figures, not an individual Veteran's details. 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 10-3567
Part II: staff
Full time employee equivalents by position, from physicians, dentists, social workers, pharmacists and dietitians to nurses, nursing assistants, therapists, psychologists, psychiatrists, administrators and other staff.
Parts III to V: nursing staffing pattern
A four week average table for ADHC, the nursing home and the domiciliary. Each table has day, evening and night shifts for Sunday to Saturday, with RN, LPN and CNA columns.
Totals and hours per patient per day
Each table ends with a total, a grand total and a line for direct care nursing hours per patient per day for that level of care.
Instructions and notice
Pages 1 and 2 hold the definitions, the calculation steps and a Paperwork Reduction Act notice that estimates an average of 30 minutes.
The instructions say the Staffing Profile consists of 5 Parts.
How to complete VA Form 10-3567
- 1
Fill in Part I
Enter operating beds or participant slots, authorized approvals, patient census (veterans and non-veterans), FTEE authorized and FTEE available, using the definitions on page 1. For ADHC, a bed means participant slots.
- 2
List staff in Part II
Enter total FTEE positions for the facility, then the breakdown for each level of care. The form gives the example of 12 R.N.'s split 10 for the nursing home, 1 for ADHC and 1 for the domiciliary. Contract and agency staff are included.
- 3
Pick four sample weeks
The instructions say to select 4 separate 1 week worked schedules (7 days) at random from the previous 12 months, with one week that includes one holiday.
- 4
Average the nursing hours
Add the hours from the 4 schedules for each RN, LPN and CNA by shift and day, and divide by 4. The form is based on 8 hour shifts: a 10 hour shift counts 8 hours in the first shift and 2 in the next, a 12 hour shift 8 and 4.
- 5
Work out hours per patient per day
Divide the total direct care nursing hours from the table by the Part I patient census (veteran plus non-veteran) multiplied by 7 days.
These steps follow the form's own instructions.
Why fill Form 10-3567 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
Filing and edition details
No address on the form
The PDF and VA's form page print no mailing address, fax number or email for this form.
Why it is collected
The notice says completion is voluntary, but VA will be unable to certify the home without a completed form. It says failure to complete it has no effect on any other benefits.
Legal authority
The form says the information is collected under the authority of Title 38 CFR Parts 51.30 and 52.30.
Edition
The PDF is dated DEC 2023 and carries OMB Control No. 2900-0883, Exp. Date: 12/31/2026. VA's form page lists a revision date of October 2015.
Related forms
10-5588
State Home Report and Statement of Federal Aid Claimed
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10-5588A
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10-10SH
State Home Program Application for Veteran Care Medical Certification
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10-0430
Application for Assistance for Hiring and Retaining Nurses at State Homes
23 fields, 2 pages
10-0460
Request for Prescription Drugs from an Eligible Veteran in a State Home
76 fields, 3 pages
Who completes VA Form 10-3567?
The form is a staffing profile for a VA inspection of a State Home. Its instructions are written for the home completing it.
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Questions about Form 10-3567
What is VA Form 10-3567?
It is the State Home Inspection, Staffing Profile. It records a State Home's beds, patient census, staff and nursing hours for each level of care, and carries a date of inspection.
Who fills in VA Form 10-3567?
The State Home. The form asks for facility figures, and its notice says VA will be unable to certify the home without a completed form.
What do ADHC, NHC and DOM mean on the form?
They are the levels of care the instructions name: adult day health care (ADHC), nursing home and domiciliary. Parts III, IV and V cover them in that order.
How are direct care nursing hours per patient per day calculated?
The form divides the total direct care nursing hours from the Part III to V tables by the Part I patient census (veteran plus non-veteran) multiplied by 7 days.
How are 10 or 12 hour shifts counted?
The form is based on 8 hour shifts. It says to count 8 hours in the first shift and 2 in the following shift for a 10 hour shift, and 8 and 4 for a 12 hour shift.
Do contract and agency staff count?
Yes. The instructions say contract and agency staff shall be included in Part II.