36C24219R0109-004.pdf

VA New York / New Jersey Health Care Network

HCHV Contract Residential Care Program

Incident Report

(To be completed and faxed to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring.)

Name of Veteran: __________________________________________________________________________

Social Security No.: ________________________________________________________________________

Agency / Facility: __________________________________________________________________________

Contract No.: ______________________________________________________________________________

Description of the Incident

Date of Incident: ________________________ ___ Time of Incident: ____________________________

Location of Incident: _______________________________________________________________________

Type of Incident:

Death (N)

Fire (N)

Drug / Police Raid (N)

Suicide / Suicide Attempt

911 Call (Police / Fire Dept. / Paramedics / Other)

Severe Medical Illness / Emergency

Severe Psychiatric Illness / Emergency

Sexual Assault

Act of violence by veteran against other resident(s) or staff

Abusive behavior by veteran against staff

Act of violence by other resident(s) or staff against veteran

Abusive behavior by staff against veteran

Accident (Specify: ______________________________________________________)

Medication Problem:

◊ Medication not sent

◊ Incorrect medication sent

◊ Missing medications

◊ Adverse drug reaction

Other (Specify: _________________________________________________________)

(N) = National report required

D.6 INCIDENT REPORT FORM

Brief Description of the Incident (please include circumstances leading up to the incident, names of witnesses, if any, and outcomes; attach additional pages as needed):

Action(s) taken by Contract Provider:

Name of VA Staff Contacted: ________________________________________________________________

Report Completed By: ______________________________________________________________________

Title: _______________________________________________ Date: __________________________

Signature: ________________________________________________________________________________

Phone: ___________________________________________________________________________________

For VA HCHV Contract Residential Care Liaison

Additional information and actions taken including date(s):

Report filed:

Nationally Sent to: _______________________________________________________________

Date: ________________________

Locally Sent to: _______________________________________________________________

Date: ________________________

Follow Up Required (if any):

VA Liaison: ______________________________________________________________________________

Signature: _________________________________________________ Date: ___________________