20200304223824organizationalcultureanddesignwk31.pptx20200304223109vha_10_10cg1
Assignment Content
- Complete the Hewlett-Packard Case Study Analysis.
Submit your analysis.
Prepare a 7- to 10-slide Microsoft® PowerPoint®, Prezi, or Microsoft® Sway®presentation describing your analysis of the Hewlett-Packard Case Study. Describe how you addressed the five (5) Case Study topics/questions.Please be prepared to present your analysis and recommendation in class on Week 6.
Please Note:50% of your grade will be your written analysis (see breakdown below) 25% Microsoft® Word document 25% Microsoft® PowerPoint®, Prezi, or Microsoft® Sway® presentation50% of your grade will be your Verbal Presentation in Class on Week 6Wk 6 – Apply: Hewlett-Packard Case Study Analysis [due Mon]Rubric Details
Maximum Score130 pointsSupertrends
15% of total gradeOutstanding Achievement Comprehensive and in-depth identification of supertrends included and skillfully tied in with the elements of the case. 19.5Very Good Work Identification of supertrends included and appropriately identified as change drivers. 16.6Average Work Identification of supertrends included but were underdeveloped. 14.6Unacceptable Work Identification of supertrends missing or inadequate. 9.8
Forces of Organizational Change
15% of total gradeOutstanding Achievement Forces for organizational change were thoroughly identified and explanation was well developed and insightful.19.5Very Good Work Forces for organizational change were appropriately identified and explanation was well developed. 16.6Average Work Forces for organizational change were identified, but explanation was minimal.14.6Unacceptable Work Forces for organizational change were not properly identified or the explanation was illogical or missing. 9.8
Use of Lewin’s and Kotter’s Models
15% of total gradeOutstanding Achievement Recommendations of models as potential change drivers were well developed and insightful. 19.5Very Good Work Recommendations of models as potential change drivers were appropriately addressed. 16.6Average Work Recommendations of models as potential change drivers were addressed, but explanation was minimal. 14.6Unacceptable Work Recommendations of models as potential change drivers were illogical or missing.9.8
Fostering Innovation
15% of total gradeOutstanding Achievement In-depth assessment of HP’s adherence to fostering innovation was complete and well developed. 19.5Very Good Work Description and explanation of HP’s fostering innovation was sufficiently accomplished. 16.6Average Work Description and explanation of HP’s fostering innovation was minimally accomplished. 14.6Unacceptable Work Description and explanation of HP’s fostering innovation was not done or was done poorly. 9.8
Advice for HP
15% of total gradeOutstanding Achievement Student’s advice for HP was insightful and valuable. 19.5Very Good Work Student’s advice for HP was appropriately and thoughtfully communicated. 16.6Average Work Student’s advice for HP included, but was underdeveloped. 14.6Unacceptable Work Student’s advice for HP non-existent or minimal. 9.8
Tone
9% of total gradeOutstanding Achievement Tone and level of discussion exemplify high level of ability to communicate in academic writing. 11.7Very Good Work Tone and level of discussion is at an appropriate level. 9.9Average Work Tone and level of discussion is approaching expected level, but writing should be elevated.8.8Unacceptable Work Tone and level of discussion is not appropriate to the content and assignment. 5.9
Sentence Structure
8% of total gradeOutstanding Achievement Answers are fully organized in a logical and coherent manner; transitions are smooth and flow seamlessly from one point to the next. 10.4Very Good Work Answers are generally organized in a logical and coherent manner; transitions for the most part are smooth. 8.8Average Work Answers are generally organized in a logical and coherent manner; transitions, however, are awkward. 7.8Unacceptable Work Answers are organized in a logical or coherent manner, but not both. 5.2
Grammar
8% of total grade
Must Read: Please read instructions carefully
I sent you a power point that another tutor did which was not a good grade, a lot of info was left out maybe cuz they didn’t read the instructions carefully, the power point looked good just didn’t contain the info that was needed2 Attachments
Organizational Culture and Design
Derrick Bradley
MGT/521
10 March 2020
1
Introduction
Ideally, organizational culture is communicated to all workers. It directs what they do and how they do it. Additionally, it is embedded in all activities in a bid to improve operational efficiency. As for IDEO, the culture is about helping one another in complex tasks. Employees work as teams and whenever one needs assistance, it becomes easy to get it. As such, culture makes all tasks easy. Different techniques are used to realize it as discussed in the following slides.
2
Organizational culture is communicated to all workers
It directs what they do and how they do it
IDEO culture is about helping one another in complex tasks
The culture makes all tasks easy
Different techniques are used to realize it
Organizational culture at IDEO
Leadership conviction to encourage collaborations (Kinicki & Williams, 2020)
A company culture with employees’ roles as helpers (as seen in fig.1 here)
Every worker has been assigned a helper
Understanding helpfulness as better than the competition
IDEO’s leadership normally encourages collaborations among the employees (Kinicki & Williams, 2020). Complex problems require more help. To ensure that the employees can work on complex problems, they join hands and find solutions. Brainstorming is one way they apply. As part of the company culture, the workers act as helpers, as seen in fig.1 presented. They develop networks and participate in daily activities as a way to build the helping culture. It is also crucial to note that each worker is assigned a helper so that he/she can offer a helping hand whenever the task is complicated. Finally, the workers have grown to deeply understand bout helpfulness. It produces a better outcome than the competition. When people join hands and share their thoughts, tasks become simple and doable compared to when each person is engaged in a task trying to compete with others.
3
Techniques used by IDEO
Leaders’ support.
Using collaborative approaches like brainstorming, clan culture (Kinicki & Williams, 2020).
Fig.2 indicates a brainstorming session at IDEO.
Teamwork vs. competition
Open offices, easy to access helpers
IDEO has embedded the organizational culture through several techniques. First, support from the leaders has made it easy for people to interact freely and learn from one another. Again, leaders have allowed employees to have helpers. Without leadership support, the culture would not have succeeded. Another technique is incorporating collaborative approaches like brainstorming in finding solutions (as in fig.2 above by IDEO workers). It promotes the clan culture where employees participate (Kinicki & Williams, 2020). The process brings people together to find ways of addressing some organizational challenges. Teamwork has also promoted a helping culture. It is contrary to competition where people work on individual tasks which can be complicated and take more time. Lastly, IDEO has open offices where workers can easily access helpers and have the problem solved.
4
Organizational culture used in our organization
Our organizational culture entails better salaries and performance-based incentives (Al Mamun, & Hasan, 2017).
Employee recognition
Employee engagement (Ruck et al., 2017).
Many employee benefits (Kinicki & Williams, 2002).
IDEO organizational culture can be implemented in our organization
Our organizational culture entails better salaries and performance-based incentives meant to make employees strive to improve their productivity to increase their salaries (Al Mamun, & Hasan, 2017). Moreover, there is an employee recognition program where the best employees are recognized and awarded. The program makes others work hard so that they too can be recognized. Employee engagement helps us communicate with the management and offer our feedback as seen in fig. 3 (Ruck et al., 2017). We also have an innovative workplace culture whereby the workers are given the opportunity to explain their ideas and if they work, they are rewarded for that. Finally, we benefit from company perks like retirement, health, and life insurance as well as paid leaves (Kinicki & Williams, 2002). With the success that IDEO has achieved, its organizational culture can be implemented in our organization.
5
Mechanisms Our Company Can Use To Adopt The IDEO Culture
Encourage teamwork and group perks. Fig.4 has IDEO employees posing as a team.
Have employees get helpers
Exercise open office culture to reach one another
Have departmental forums to address complex challenges
To adopt the IDEO organizational culture of helping in our organization, the company must encourage teamwork and group perks. Teamwork entails working as groups and not individuals (as seen in fig. 4, IDEO workers). Again, instead of awarding and recognizing individual workers as we normally do, groups should be recognized. As for group perks, these are team awards such as group vacations to rewards groups and not individuals. The employees should also get helpers, people who can be easily accessed whenever there is a problem or a difficult task. Importantly, the organization needs to exercise an open office culture so that a worker can reach one another at any time. Finally, we must have departmental forums to address complex challenges. The brainstorming process is one way that employees within the department can effectively gather ideas of addressing issues.
6
Conclusion
IDEO’s organizational culture is about helping.
All tasks are easy because of concerted efforts are made.
Techniques used include collaborations, teamwork, and open culture.
Our organization use performance-based incentives, employee recognition, innovative workplace culture, and many employee benefits.
To adopt the culture, we need to encourage teamwork and group perks, employees get helpers, utilize open office and have departmental forums.
Undeniably, IDEO’s organizational culture is about helping. All tasks become easy when concerted efforts are made. Employees can easily access help from their colleagues when they need it. They leverage techniques such as collaborations, teamwork, and open culture. In our organization, we use performance-based incentives, employee recognition, innovative workplace culture, and many employee benefits. We can adopt IDEO’s culture to make all tasks easy. To adopt the culture, we need to encourage teamwork and group perks, employees get helpers, utilize the open office, and have departmental forums.
7
References
Al Mamun, C.A., & Hasan, M. N. (2017). Factors affecting employee turnover and sound retention strategies in business organization: a conceptual view. Problems and Perspectives in Management, 1(1), 63-71
Kinicki, A., & Williams, B. (2020). Management: A Practical Introduction (9th ed). New York, NY: McGraw-Hill.
Ruck et al. (2017). Employee voice: An antecedent to organisational engagement? Public Relations Review, http://dx.doi.org/10.1016/j.pubrev.2017.04.008
List of references
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10-10CG
VA F
OR
M April 2016
Instructions for Completing Application for the Program of Comprehensive Assistance
for Family Caregivers
Please Read Before You Start . . .
Caregiver Support Coordinator (CSC):
A VA clinical professional who connects Caregivers of Veterans with VA and community resources offering supportive
programs and services. Caregiver Support Coordinators are located at every VA medical center and are designated
specialists in Caregiving issues.
Family Member:
A member of the Veteran’s or Servicemember’s family (including a parent, a spouse, a son or daughter, a step-family
member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will
do so if approved as a Primary or Secondary Family Caregiver.
Injured in the Line of Duty (LOD):
An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran’s or
Servicemember’s willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by
desertion, or absent without leave which materially interfered with the performance of military duty.
Power of Attorney (POA):
A Power of Attorney is an authorization for someone to act on the Veteran’s or Servicemember’s behalf when completing
this form.
Primary Family Caregiver:
A Family Member (defined herein), who is designated as a “primary provider of personal care services” under 38 U.S.C.
§1720G(a)(7)(A); and who meets the requirements of 38 C.F.R. §71.25.
Representative:
Refers to a Veteran’s or Servicemember’s court-appointed legal guardian or special guardian, Durable POA for Health
Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this
application.
Secondary Family Caregiver:
An individual approved as a “provider of personal care services” for the eligible Veteran under 38 U.S.C. §1720G(a)(7)(A);
meets the requirements of 38 C.F.R. §71.25; and generally serves as a back-up to the Primary Family Caregiver.
Stipend:
An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a
seriously injured eligible Veteran (as defined in 38 C.F.R §71.15).
Definitions of terms used in this form
What is VA Form 10-10CG used for?
To apply for VA’s Program of Comprehensive Assistance for Family Caregivers. VA will use the information on this form to
assist in determining your eligibility; a clinical assessment will also be required. An eligible Veteran may appoint one (1)
Primary Family Caregiver and up to two (2) Secondary Family Caregivers. On average, it will take 15 minutes to complete
the application including the time it will take you to read instructions, gather the necessary facts and fill out the form. Each
time a new Caregiver is appointed a new Form 10-10CG is required.
Where can I get help filling out the form and answers to questions?
You may use ANY of the following to request assistance: Ask VA to help you fill out the form by calling us at 1-877-222-
VETS (8387). Access VA’s website at http://www.va.gov and select “Contact the VA”. Locate and contact the Caregiver
Support Coordinator at your nearest VA health care facility. A Caregiver Support Coordinator locator is available at http://
www.caregiver.va.gov/. Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service
Organization.
http://www.caregiver.va.gov/
http://www.caregiver.va.gov/
10-10CGVA FORM April 2016
Who should apply for VA’s Program of Comprehensive Assistance for Family Caregivers?
IF THE INDIVIDUAL IS A:
Veteran
or
Servicemember
who has been issued a
date of medical discharge
from the military
AND
AND
THEN
Requires on-going supervision or assistance
with performing basic functions of everyday
life due to a serious injury or mental disorder
(including traumatic brain injury,
psychological trauma or other mental
disorder) incurred or aggravated in the line
of duty on or after September 11, 2001
Requires at least 6 months
of continuous Caregiver
support
The Veteran or Servicemember
may meet the criteria for VA’s
Program of Comprehensive
Assistance for Family Caregivers.
Complete this form to apply
Veterans and Servicemembers who do not meet the criteria for VA’s Program of Comprehensive Assistance for Family Caregivers
may be eligible for VA health benefits and other caregiver support services. To find out about other caregiver support services,
contact the Caregiver Support Coordinator (CSC) at your local VA health care facility. To obtain the name of your local CSC, contact
the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.va.gov and use the Find Your Local Caregiver Support
Coordinator option.
THE PAPERWORK REDUCTION ACT
This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public
reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions,
gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.
PRIVACY ACT INFORMATION
Privacy Act Information: Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 101,
5303A, 1705, 1710, 1720B, and 1720G, in order for VA to determine your eligibility for medical benefits. Information you supply may be
verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a
“routine use” disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records –VA” (24VA19),
“Enrollment and Eligibility Records –VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records–
VA” (54VA17) and in accordance with the VHA Notice of Privacy Practices. Providing the requested information, including Social Security
Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health
care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA
your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons
claiming or receiving VA benefits, and their records, and for other purposes authorized or required by law.
1. Read Paperwork Reduction and Privacy Act Information.
2. The Veteran or an individual delegated as the Veteran’s representative/POA must sign and date the form.
3. Attach POA/Representation documents to the application, if applicable.
4. For expedited processing, mail this application to:
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Ste 200
Atlanta, GA 30329-1647
Submitting your application.
Answer all questions on the form. If you are not enrolled in VA’s health care system or are currently Active Duty undergoing
medical discharge, submit VA Form 10-10EZ “Application for Health Benefits” with this form. Enrolled Veterans may submit VA
Form 10-10EZR “Health Benefits Renewal Form” with their completed VA Form 10-10CG to provide information updates. Do NOT
exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran’s or Servicemember’s
representative or POA may complete this application; however the POA/Representation documents must be provided with this
application.
Getting Started:
If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local VA
Medical Center Caregiver Support Coordinator (CSC). To obtain the name of your local CSC, contact the Caregiver Support Line
at 1-855-260-3274 or go to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.
SECTION I –VETERAN AND SERVICEMEMBER GENERAL INFORMATION
Directions for Section I –Veteran/Servicemember, representative or POA, please answer all questions, sign and date.
SECTION II –PRIMARY FAMILY CAREGIVER GENERAL INFORMATION
Directions for Section II –Primary Family Caregiver applicant, please answer all questions, including health insurance information,
sign and date.
SECTION III –SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION
Directions for Section III –Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/
Servicemember may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to
appoint a Secondary Family Caregiver at a later time, Sections I and III in a new 10-10CG must be completed.
http://www.caregiver.va.gov
http://www.caregiver.va.gov
10-10CG Page of VA FORM April 2016
Application for Comprehensive Assistance for Family Caregivers Program
Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility
Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA 30329-1647, for expedited processing; or, hand carry it to your local VA Medical Center Caregiver
Support Coordinator (CSC). The date the application is received by VA is the date the application process begins. At this time VA does not provide the Program
of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.
SECTION I – VETERAN/SERVICEMEMBER
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements
or claims
Last Name First Name Middle
Name
Date of Birth (mm-dd-yyyy)Social Security Number
Male Female
Gender
Date
Current Street Address
City State Zip Code
Telephone Number (Including Area Code) Cell Number (Including Area Code)
Name of VA medical center or clinic where you receive or plan to receive health care services:
Email Address
Yes No
Enrolled in VA Health Care?
Name of facility where you last received medical treatment: Hospital Clinic
I certify that I give consent to the individual(s) named in this application to perform personal care services for me upon being approved as
Primary and/or Secondary Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers.
I certify that the information above is correct and true to the best of my knowledge and belief.
SECTION II – PRIMARY FAMILY CAREGIVER
Middle NameFirst NameLast Name
Social Security Number Date of Birth (mm-dd-yyyy)
Male Female
Gender
Current Street Address
City State Zip Code
Estimated Burden: 15 min.
OMB Number 2900-0768
Expiration Date: 04/30/2018
Veteran/Servicemember/Representative/POA Signature
10-10CG Page of VA FORM April 2016
SECTION III – SECONDARY FAMILY CAREGIVER – Complete if appointing a Secondary Caregiver
Last Name First Name Middle Name
Date of Birth (mm-dd-yyyy)Social Security Number
Male Female
Gender
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements
or claims
I certify that the information above is correct and true to the best of my knowledge and belief.
Telephone Number (Including Area Code) Cell Number (Including Area Code)
Relationship to Veteran (e.g., Spouse, Parent, Child, Other)E-mail Address
Yes No
Enrolled in Medicaid or Medicare?
Name
Other Health Insurance?
Yes No
SECTION II – PRIMARY FAMILY CAREGIVER (continued)
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Primary Family Caregiver for the Veteran or Servicemember named on this
application.
I understand that the Veteran may revoke my designation as Primary Family Caregiver at any time and that the Secretary of the
Department of Veterans Affairs
(or designee) may remove me from this position immediately if I fail to comply with the Program
requirements as defined by law.
I understand that participation in the Program of Comprehensive Assistance for Family Caregivers does not create an
employment relationship with the Department of Veterans Affairs.
I certify that I am a family member of the Veteran or Servicemember named in this application.
I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
OR
Date
Current Street Address
City State Zip Code
Cell Number (Including Area Code)Telephone Number (Including Area Code)
Relationship to Veteran (e.g., Spouse, Parent, Child, Other)Email Address
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements
or claims
Primary Family Caregiver Signature
10-10CG Page of VA FORM April 2016
SECONDARY FAMILY CAREGIVER – Complete if appointing more than one Secondary Caregiver.
Last Name First Name Middle Name
Date of Birth (mm-dd-yyyy)Social Security Number
Male Female
Gender
Current Street Address
City State Zip Code
Telephone Number (Including Area Code) Cell Number (Including Area Code)
Relationship to Veteran (e.g., Spouse, Parent, Child, Other)Email Address
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements
or claims
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this
application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary
of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the
Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
I certify that I am a family member of the Veteran or Servicemember named in this application.
I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
OR
Date
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this
application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of
the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the
Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
I certify that I am a family member of the Veteran or Servicemember named in this application.
I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
OR
Date
SECTION III – SECONDARY FAMILY CAREGIVER (Continued)
Secondary Family Caregiver Signature
Secondary Family Caregiver Signature
10-10CG
10-10 C G
VA FORM April 2016
V A FORM
10-10CG
10-10 C G
Page
of
VA FORM
April 2016
V A FORM
..\logos\FORMLOGO
Logo: Department of Veterans Affairs
Instructions for Completing Application for the Program of Comprehensive Assistance for Family Caregivers
Please Read Before You Start . . .
Caregiver Support Coordinator (CSC):
A VA clinical professional who connects Caregivers of Veterans with VA and community resources offering supportive programs and services. Caregiver Support Coordinators are located at every VA medical center and are designated specialists in Caregiving issues.
Family Member:
A member of the Veteran’s or Servicemember’s family (including a parent, a spouse, a son or daughter, a step-family member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or Secondary Family Caregiver.
Injured in the Line of Duty (LOD):
An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran’s or Servicemember’s willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty.
Power of Attorney (POA):
A Power of Attorney is an authorization for someone to act on the Veteran’s or Servicemember’s behalf when completing this form.
Primary Family Caregiver:
A Family Member (defined herein), who is designated as a “primary provider of personal care services” under 38 U.S.C. §1720G(a)(7)(A); and who meets the requirements of 38 C.F.R. §71.25.
Representative:
Refers to a Veteran’s or Servicemember’s court-appointed legal guardian or special guardian, Durable POA for Health Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this application.
Secondary Family Caregiver:
An individual approved as a “provider of personal care services” for the eligible Veteran under 38 U.S.C. §1720G(a)(7)(A); meets the requirements of 38 C.F.R. §71.25; and generally serves as a back-up to the Primary Family Caregiver.
Stipend:
An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured eligible Veteran (as defined in 38 C.F.R §71.15).
Caregiver Support Coordinator (C S C):
A V A clinical professional who connects Caregivers of Veterans with V A and community resources offering supportive programs and services. Caregiver Support Coordinators are located at every V A medical center and are designated specialists in Caregiving issues.
Family Member:
A member of the Veteran’s or Servicemember’s family (including a parent, a spouse, a son or daughter, a step-family member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or Secondary Family Caregiver.
Injured in the Line of Duty (L O D):
An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran’s or Servicemember’s willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty.
Power of Attorney (P O A):
A Power of Attorney is an authorization for someone to act on the Veteran’s or Servicemember’s behalf when completing this form.
Primary Family Caregiver:
A Family Member (defined herein), who is designated as a “primary provider of personal care services” under 38 U S C §1 7 2 0G(a)(7)(A); and who meets the requirements of 38 C F R §71.25.
Representative:
Refers to a Veteran’s or Servicemember’s court-appointed legal guardian or special guardian, Durable P O A for Health Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this application.
Secondary Family Caregiver:
An individual approved as a “provider of personal care services” for the eligible Veteran under 38 U S C §1 7 2 0G(a)(7)(A); meets the requirements of 38 C F R §71.25; and generally serves as a back-up to the Primary Family Caregiver.
Stipend:
An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured eligible Veteran (as defined in 38 C F R §71.15).
Definitions of terms used in this form
What is VA Form 10-10CG used for?
To apply for VA’s Program of Comprehensive Assistance for Family Caregivers. VA will use the information on this form to assist in determining your eligibility; a clinical assessment will also be required. An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family Caregivers. On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the necessary facts and fill out the form. Each time a new Caregiver is appointed a new Form 10-10CG is required.
Where can I get help filling out the form and answers to questions?
You may use ANY of the following to request assistance: Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387). Access VA’s website at http://www.va.gov and select “Contact the VA”. Locate and contact the Caregiver Support Coordinator at your nearest VA health care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.va.gov/. Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service Organization.
What is V A Form 10-10C G used for?
To apply for V A’s Program of Comprehensive Assistance for Family Caregivers. V A will use the information on this form to assist in determining your eligibility; a clinical assessment will also be required. An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family Caregivers. On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the necessary facts and fill out the form. Each time a new Caregiver is appointed a new Form 10-10C G is required.
Where can I get help filling out the form and answers to questions?
You may use ANY of the following to request assistance: Ask V A to help you fill out the form by calling us at 1-8 7 7-2 2 2-VETS (8 3 8 7). Access V A’s website at http://www.V A.gov and select “Contact the V A”. Locate and contact the Caregiver Support Coordinator at your nearest V A health care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.V A.gov/. Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service Organization.
Who should apply for VA’s Program of Comprehensive Assistance for Family Caregivers?
IF THE INDIVIDUAL IS A:
Veteran
or
Servicemember
who has been issued a date of medical discharge from the military
AND
AND
THEN
Requires on-going supervision or assistance with performing basic functions of everyday life due to a serious injury or mental disorder (including traumatic brain injury, psychological trauma or other mental disorder) incurred or aggravated in the line of duty on or after September 11, 2001
Requires at least 6 months of continuous Caregiver support
The Veteran or Servicemember may meet the criteria for VA’s Program of Comprehensive Assistance for Family Caregivers. Complete this form to apply
The Veteran or Servicemember may meet the criteria for V A’s Program of Comprehensive Assistance for Family Caregivers. Complete this form to apply
Veterans and Servicemembers who do not meet the criteria for VA’s Program of Comprehensive Assistance for Family Caregivers may be eligible for VA health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver Support Coordinator (CSC) at your local VA health care facility. To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.
Veterans and Servicemembers who do not meet the criteria for V A’s Program of Comprehensive Assistance for Family Caregivers may be eligible for V A health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver Support Coordinator (C S C) at your local V A health care facility. To obtain the name of your local C S C, contact the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.V A.gov and use the Find Your Local Caregiver Support Coordinator option.
THE PAPERWORK REDUCTION ACT
This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.
This information collection is in accordance with the clearance requirements of section 3 5 0 7 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid O M B control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.
PRIVACY ACT INFORMATION
Privacy Act Information: Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, and 1720G, in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a “routine use” disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records –VA” (24VA19), “Enrollment and Eligibility Records –VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records–VA” (54VA17) and in accordance with the VHA Notice of Privacy Practices. Providing the requested information, including Social Security Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits, and their records, and for other purposes authorized or required by law.
Privacy Act Information: Privacy Act Information: V A is asking you to provide the information on this form under 38 U S C Sections 101, 5 3 0 3. A, 1 7 0 5, 1 7 1 0, 1 7 2 0B, and 1 7 2 0G, in order for V A to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. V A may disclose the information that you put on the form as permitted by law. V A may make a “routine use” disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records –V A” (2 4 V A 1 9), “Enrollment and Eligibility Records –V A” (1 4 7 V A 1 6), and “Health Administration Center Civilian Health and Medical program Records–V A” (5 4 V A 1 7) and in accordance with the V H A Notice of Privacy Practices. Providing the requested information, including Social Security Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide V A your Social Security Number, V A will use it to administer your V A benefits. V A may also use this information to identify Veterans and persons claiming or receiving V A benefits, and their records, and for other purposes authorized or required by law.
1. Read Paperwork Reduction and Privacy Act Information.
2. The Veteran or an individual delegated as the Veteran’s representative/POA must sign and date the form.
2. The Veteran or an individual delegated as the Veteran’s representative/P O A must sign and date the form.
3. Attach POA/Representation documents to the application, if applicable.
3. Attach P O A/Representation documents to the application, if applicable.
4. For expedited processing, mail this application to:
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Ste 200
Atlanta, GA 30329-1647
4. For expedited processing, mail this application to:
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2 9 5 7 Clairmont Road Northeast, Suite 200
Atlanta, Georgia 3 0 3 2 9-1 6 4 7
Submitting your application.
Answer all questions on the form. If you are not enrolled in VA’s health care system or are currently Active Duty undergoing medical discharge, submit VA Form 10-10EZ “Application for Health Benefits” with this form. Enrolled Veterans may submit VA Form 10-10EZR “Health Benefits Renewal Form” with their completed VA Form 10-10CG to provide information updates. Do NOT exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran’s or Servicemember’s representative or POA may complete this application; however the POA/Representation documents must be provided with this application.
Answer all questions on the form. If you are not enrolled in V A’s health care system or are currently Active Duty undergoing medical discharge, submit V A Form 10-10E Z “Application for Health Benefits” with this form. Enrolled Veterans may submit V A Form 10-10E Z R “Health Benefits Renewal Form” with their completed V A Form 10-10C G to provide information updates. Do NOT exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran’s or Servicemember’s representative or P O A may complete this application; however the P O A/Representation documents must be provided with this application.
Getting Started:
If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local VA Medical Center Caregiver Support Coordinator (CSC). To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.
If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local V A Medical Center Caregiver Support Coordinator (C S C). To obtain the name of your local C S C, contact the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.V A.gov and use the Find Your Local Caregiver Support Coordinator option.
SECTION I –VETERAN AND SERVICEMEMBER GENERAL INFORMATION
SECTION 1 –VETERAN AND SERVICEMEMBER GENERAL INFORMATION
Directions for Section I –Veteran/Servicemember, representative or POA, please answer all questions, sign and date.
Directions for Section 1 –Veteran/Servicemember, representative or P O A, please answer all questions, sign and date.
SECTION II –PRIMARY FAMILY CAREGIVER GENERAL INFORMATION
SECTION 2 –PRIMARY FAMILY CAREGIVER GENERAL INFORMATION
Directions for Section II –Primary Family Caregiver applicant, please answer all questions, including health insurance information, sign and date.
Directions for Section 2 –Primary Family Caregiver applicant, please answer all questions, including health insurance information, sign and date.
SECTION III –SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION
SECTION 3 –SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION
Directions for Section III –Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/Servicemember may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to appoint a Secondary Family Caregiver at a later time, Sections I and III in a new 10-10CG must be completed.
Directions for Section 3 –Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/Servicemember may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to appoint a Secondary Family Caregiver at a later time, Sections 1 and 3 in a new 10-10C G must be completed.
..\logos\FORMLOGO
V A LOGO
Application for Comprehensive Assistance for Family Caregivers Program
Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA 30329-1647, for expedited processing; or, hand carry it to your local VA Medical Center Caregiver Support Coordinator (CSC). The date the application is received by VA is the date the application process begins. At this time VA does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.
Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road Northeast, Suite 200, Atlanta, Georgia 3 0 3 2 9-1 6 4 7, for expedited processing; or, hand carry it to your local V A Medical Center Caregiver Support Coordinator (C S C). The date the application is received by V A is the date the application process begins. At this time V A does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.
SECTION I – VETERAN/SERVICEMEMBER
SECTION 1 – VETERAN/SERVICEMEMBER
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Gender
Enrolled in VA Health Care?
Enrolled in V A Health Care?
I certify that I give consent to the individual(s) named in this application to perform personal care services for me upon being approved as Primary and/or Secondary Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers.
I certify that the information above is correct and true to the best of my knowledge and belief.
SECTION II – PRIMARY FAMILY CAREGIVER
SECTION 2 – PRIMARY FAMILY CAREGIVER
Gender
Estimated Burden: 15 min.
OMB Number 2900-0768
Expiration Date: 04/30/2018
Estimated Burden: 15 minutes
O M B Number 2 9 0 0-0 7 6 8
Expiration Date: XX/XX/XXXX
Veteran/Servicemember/Representative/POA Signature
SECTION III – SECONDARY FAMILY CAREGIVER – Complete if appointing a Secondary Caregiver
SECTION 3 – SECONDARY FAMILY CAREGIVER – Complete if appointing a Secondary Caregiver
Gender
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
I certify that the information above is correct and true to the best of my knowledge and belief.
Enrolled in Medicaid or Medicare?
Other Health Insurance?
SECTION II – PRIMARY FAMILY CAREGIVER (continued)
SECTION 2 – PRIMARY FAMILY CAREGIVER (continued)
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Primary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran may revoke my designation as Primary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.
I understand that participation in the Program of Comprehensive Assistance for Family Caregivers does not create an employment relationship with the Department of Veterans Affairs.
OR
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Primary Family Caregiver Signature
SECONDARY FAMILY CAREGIVER – Complete if appointing more than one Secondary Caregiver.
Gender
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
OR
I certify that I am at least 18 years of age.
Check one:
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.
I certify that the information above is correct and true to the best of my knowledge and belief.
OR
SECTION III – SECONDARY FAMILY CAREGIVER (Continued)
SECTION 3 – SECONDARY FAMILY CAREGIVER (Continued)
Secondary Family Caregiver Signature
Secondary Family Caregiver Signature
8.2.1.4029.1.523496.503679
Application for Comprehensive Assistance for Family Caregivers Program
Department of Veterans Affairs
Application for Comprehensive Assistance for Family Caregivers Program
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