36C26220R0078-003.pdf

Grant & Per Diem Incident Report

(Incident to be reported within 24 hours or 1st working day after event)

Name of Veteran Social Security

Facility: Project #:

Date: Time: Location of the incident:

Type of incident:

Death (including suicide and overdose) (N) Fire (N)

Sexual assault (L) 911call (police/fire department/paramedic

Severe medical illness (L) Other medical illness

Act of violence by veteran (L) Physical abuse to veteran by staff (L)

Injury to veteran by another resident (L) Verbal abuse of veteran by staff (L)

Verbal or physical abuse directed against staff (L) Accident:

Drug/police raid (N) Medication problem (L)

Veteran obtaining medications from multiple sources Medication not sent

Veteran refusing to take medications as prescribed Missing medications

Other (please specify)

Was incident seen? No Yes

S. Actions taken:

Veteran sent to VA emergency room/walk in clinic Veteran sent to non-VA facility

Veteran arrested Veteran left facility independently

ATTACHMENT A - Incident Report

Veteran referred back to VA mental health Veteran referred to community care for f/u

Veteran referred to case manager/liaison Veteran discharged from program

No action taken Other (please specify)

Veteran transported to building 500 emergency room for further treatment

Telephone

Liaison Program coordinator other (specify reason) Email

Report filed by: Title:

Signature: Date:

For VA completion only:

Follow up/Disposition: to be completed by VA liaison and attached to this report