36C25518R0327-018.pdf

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 Page 2

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:

Sent to: _______________________________________________________________

Date: ________________________

Follow Up Required (if any):

VA Liaison:

Signature: _________________________________________________ Date: ___________________