9-Appendix E - BLANK-OPEH-Incident-Report-April-2023 (1).pdf
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- Attached to
- Rental Subsidy and Services Program (RSSP)
- Solicitation number
- RFP2000004276
- Issued by
- Fairfax County, Virginia
About this file
This document is an Incident Report Form and Instructions issued by the Office to Prevent and End Homelessness (OPEH) in Fairfax County, Virginia, applicable to all contracted service providers operating within the county's homelessness prevention and support programs. The form serves as a mandatory reporting mechanism for serious incidents occurring within the scope of contracted programs serving low-income individuals and families experiencing homelessness, including those with physical, behavioral, and sensory disabilities, survivors of domestic violence, and transition age youth. Providers must submit incident reports within 72 hours of occurrence for incidents including death, physical assault, sexual assault, drug use or distribution, weapon possession, destruction of property, criminal activity, child protective services involvement, injuries on site, and incidents requiring emergency personnel response. The form requires providers to document the incident type, date and time of occurrence, location, staff involved, HMIS identification numbers of affected program participants, detailed descriptions of the incident and staff response, and whether termination or trespass notices resulted from the incident, while explicitly prohibiting the inclusion of personally identifiable information in the report.
Critical incidents involving death, weapon possession, weapon-related injury, serious property damage, fire, or media coverage must be reported immediately by phone to the appropriate OPEH Program Manager, Division Director, or Deputy Director rather than through the standard form submission process. Staff are required to make every attempt to contact OPEH personnel as soon as possible, and for incidents occurring after 5:00 p.m. or on weekends, contact must be directed to the Deputy Director. The form distinguishes reporting pathways based on program type, with incidents related to singles programs directed to the OPEH Singles Program Manager and incidents related to family programs directed to the OPEH Families Program Manager via secure email. The procedures emphasize comprehensive documentation while maintaining participant privacy and ensuring rapid escalation of the most serious incidents to senior OPEH leadership.
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Text version
OPEH INCIDENT REPORT INSTRUCTIONS
Office to Prevent and End Homelessness
Fairfax County
For incidents related to programs for singles, email the OPEH Singles Program Manager.
For incidents related to programs for families, email the OPEH Families Program Manager.
Incident Report Form April 2023
• Death
• Physical fight or assault
• Drug distribution on property
• Use of weapons
• Sexual Assault
• Injury on site
• Destruction of property
• Drug use on property
• Criminal activity
• Incidents that required an emergency personnel response
• Child Protective Services (CPS) on site and/or a child is taken into CPS custody
Procedure for submission to OPEH:
• Be as descriptive as possible when providing details of the incident.
• Once completed, please send a secure email to the appropriate Program Manager at OPEH.
Please complete an Incident Report when a serious incident occurs within the scope of any contracted program with the Office to Prevent and End Homelessness (OPEH).
Serious incidents include, but are not limited to:
In most cases, incident reports must be submitted to OPEH within 72 hours of the incident taking place.
Exceptions to this policy are:
DO NOT include Personally Identifiable Information (PII) in the report.
Incidents related to the death of a program participant, weapon possession, injury caused by a weapon, serious property damage, fire, and media coverage of an incident, must reported by phone to a Program Manager, Division Director, or the Deputy Director of OPEH. Staff must make every attempt to speak with OPEH staff to report the serious incident as soon as possible.
For incidents that occur after 5:00 pm and on the weekends staff must contact the Deputy Director of OPEH.
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OPEH INCIDENT REPORT
Agency: _______________________________________ Program: _____________________________
Staff completing form: ___________________________ Staff title: ____________________________
Staff email: ____________________________________ Telephone number: ____________________
Date of submission to OPEH: ______________
Incident details
Type of incident (may check more than one)
Death Weapons Destruction of property
Physical fight or assault Sexual assault Drug use on property
Drug distribution on property Injury on site Criminal activity
Was the individual(s) terminated from the program as a result? YES NO
Was a trespass notice issued by the Police? YES NO
If yes, please include a copy of the notice.
Other: __________
Office to Prevent and End Homelessness
Fairfax County
Incident Report Form April 2023
Date and time incident occurred: ____________________________________
Location of incident: ____________________________________________________________________
HMIS number of program participant(s) involved: ___________________________________________
Name and title of staff involved: __________________________________________________________
Detailed description of the incident and response by staff: (do not include program participant names) dpina0 Placed Image
| Agency: |
| Program: |
| Staff completing form: |
| Staff title: |
| Staff email: |
| Telephone number: |
| Date of submission to OPEH: |
| Date and time incident occurred: |
| Location of incident: |
| Name and title of staff involved: |
| Name and title of staff involved1: |
| Check Box0: |
| 0: |
| 0: Off |
| 1: Off |
| 2: |
| 0: |
| 0: Off |
| 1: Off |
| 1: |
| 1: Off |
| 0: |
| 0: |
| 0: Off |
| 1: Off |
| 1: |
| 0: Off |
| 1: Off |
| 3: Off |
| 4: Off |
| 5: Off |
| Check Box1: |
| 0: |
| 0: Off |
| 1: Off |
| Detailed description of event: |
| Other: |
| HMIS numbers of program participants involved: |
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