36C25720Q0155-005.docx

West Texas VA Health Care System (WTVAHCS) HCHV Contract Residential Care Program Incident Report

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

Name of Veteran:

Last Four of Social Security No.:

Agency / Facility: Contract No.:

Description of the Incident

Date of Incident: Time of Incident:

Location of Incident:

Type of Incident:

|_| Death |_| Fire |_| Drug / Police Raid |_| 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: )

D.4 West Texas VA Health Care System (WTVAHCS) HCHV Contract Residential Care Program Incident Report

(To be completed and faxed to the VA Liaison within 24 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):

Rept. FL 122-200 (01/14) WTVAHCS

Action(s) taken by Contract Provider:

Name of VA Staff Contacted:

Report Completed By:

Title:

Date:

Signature:

Phone: