VA Form 26-0967a: Scoring Criteria for SAH Assistive Technology Grants

VA Form 26-0967a is the U.S. Department of Veterans Affairs Scoring Criteria for SAH Assistive Technology Grants. The form says applicants for SAH Assistive technology grants provide responses addressing the six criteria items it shows, one item per page. Its companion, VA Form 26-0967, names the program as the Specially Adapted Housing Assistive Technology Grant Program under 38 U.S.C. 2108.

The form calls the person completing it the technology grant applicant and asks for no Veteran's personal details. The six items ask how the new assistive technology is innovative, the unmet need it meets, how it promotes independent living, its concept, size and scope, the implementation plan, and what uniquely positions the applicant in the marketplace. If more space is needed, the form says to attach separate sheets and indicate the item number with each response.

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Top of page 1 of VA Form 26-0967a: Scoring Criteria for SAH Assistive Technology Grants, as printed by VA

What's on VA Form 26-0967a

Item 1: innovation

Describe how the new assistive technology is innovative. Page 1 also carries the Privacy Act and burden notices.

Item 2: unmet need

Explain how the new assistive technology will meet a specific, unmet need among eligible individuals.

Item 3: independent living

Explain how the new assistive technology is specifically designed to promote the ability of eligible individuals to live more independently.

Item 4: concept, size and scope

Describe the new assistive technology's concept, size and scope.

Item 5: implementation plan

Describe the plan with major milestones for bringing the technology into production and to the market. The note says the milestones must be meaningful and achievable within a specific timeframe.

Item 6: market position

Explain what uniquely positions the technology grant applicant in the marketplace and how it will help protect the interests of, or further the mission of, VA.

How to complete VA Form 26-0967a

1
Read the six criteria
The form says applicants provide responses addressing all six items, one on each page.
2
Answer items 1 to 4
Describe the innovation, the unmet need, how the technology promotes independent living, and its concept, size and scope.
3
Lay out the milestones
Item 5 asks for an implementation plan with major milestones, which the note says must be meaningful and achievable within a specific timeframe.
4
Describe the applicant
Item 6 asks what uniquely positions the technology grant applicant in the marketplace.
5
Attach extra sheets
Where more space is needed, attach separate sheets marked with the item number of each response.

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Submitting it and other details

Where to send it

The form does not print a mailing address, email or online submission option for the responses.

Extra pages

Attach separate sheets where more space is needed and indicate the item number with each response.

Privacy and burden

The Privacy Act notice says the obligation to respond is voluntary. The burden statement estimates 1 hour per respondent, per year.

Edition

The February 2025 edition supersedes the February 2022 edition, which will not be used. It carries OMB Control Number 2900-0903, which expires 02/29/2028.

Who uses VA Form 26-0967a?

Applicants for SAH Assistive technology grants
The form says these applicants provide responses addressing the six criteria items shown on it.
The technology grant applicant's business
Item 6 lets the applicant show characteristics such as its economic reliability or its status as a minority or veteran-owned business.
Applicants needing more space
The form says to attach separate sheets and indicate the item number with each response.
Companion certification
VA Form 26-0967, the debarment and suspension certification required by the regulations implementing the same grant program, shares OMB control number 2900-0903.

The form describes who answers it and what they may include.

Official sources and the blank

Official VA form page
The agency’s own page for Form 26-0967a.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form 26-0967a

What is VA Form 26-0967a?

It is the Scoring Criteria for SAH Assistive Technology Grants: six items that the form says applicants for SAH Assistive technology grants answer.

How many criteria does the form have?

Six: innovation, a specific unmet need, independent living, concept, size and scope, an implementation plan with milestones, and what uniquely positions the applicant in the marketplace.

What if an answer does not fit on the page?

The form says to attach separate sheets and indicate the item number with each response.

Can the applicant mention veteran-owned status?

Item 6 says the answer can include characteristics such as the economic reliability of the technology grant applicant or its status as a minority or veteran-owned business.

Is there a companion form?

VA Form 26-0967, the debarment and suspension certification for the same grant program, shares OMB control number 2900-0903.

VA Form 26-0967a: Scoring Criteria for SAH Assistive Technology Grants