ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx

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Attached to
G004--NEW RESIDENTIAL SERVICES BEDS (WOMEN)
Solicitation number
36C26225R0075
Issued by

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The document is a Healthcare for Homeless Veterans Incident Report form designed to track and report critical events within 24 hours or by the first working day after an incident occurs. The comprehensive incident report covers a wide range of potential events including deaths, medical emergencies, acts of violence, accidents, medication issues, and other significant occurrences involving veterans in a healthcare facility. The form requires detailed documentation such as the veteran's name, social security number, facility, date, time, location, and specific type of incident, along with actions taken following the event, such as medical treatment, referrals, or law enforcement involvement.

The incident report is associated with Solicitation Number 36C26225R0075 for "New Residential Services Beds (Women)" issued by the Department of Veterans Affairs Network Contracting Office in Long Beach, California. The solicitation is for Product Service Code G004 and NAICS Code 624229, with a response deadline of July 17, 2025, at 3 PM Pacific Time. The procurement does not involve Recovery Act funds and is part of a broader effort to provide residential services for women veterans, with multiple supporting attachments including contract rules, accessibility checklists, and various tracking and referral worksheets.

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Other files

File Type Posted
ATTACHMENT E - SQUARES.pdf PDF
36C26225R0075_2.docx DOCX document
ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
D.3 REFERENCE CONTRACT WORKSHEET.docx DOCX document
ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
S02 - 36C26225R0075 - RESIDENTIAL SERVICES updated 02.pdf PDF
ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
ATTACHMENT H - INCIDENT REPORT.docx DOCX document
ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
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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

File details come from the government source that posted it. Updated .