Attachment 6 - Incident Report.docx
DOCX document 32 KB Posted
- Attached to
- G004--CTXVCHS Healthcare for Homeless Veterans with Medically Enhanced Services - Austin, Texas
- Solicitation number
- 36C25724Q0153_1
About this file
This document contains an incident report template to be completed by providers contracted by the Central Texas VA Health Care System for their Healthcare for Homeless Veterans program in Austin, Texas. The template requires details of any incidents involving veterans served under the contract, including deaths, fires, drug incidents, medical emergencies, acts of violence, accidents, and medication issues. It requests the veteran's name, date and time of incident, location, type of incident, description of circumstances, names of witnesses, actions taken by the provider, and name and contact information of the VA staff member notified.
The related federal contract opportunity is soliciting providers to deliver medically enhanced services under the Healthcare for Homeless Veterans program in Austin, Texas. The one year contract valued at an estimated $2.5 million would be awarded by the Department of Veterans Affairs Veterans Health Administration VISN 17 to provide housing, case management, and clinical care to homeless veterans in the Austin area.
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Text version
(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: )
Central Texas VA Health Care System (CTXVAHCS) HCHV Contract Residential Care Program Incident Report 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:
File details come from the government source that posted it. Updated .