36C26220R0101-003.pdf

Healthcare for Homeless Veterans 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 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