ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx

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Attached to
G004--EMERGENCY RESIDENTIAL BEDS - SPA 5-LDSH
Solicitation number
36C26225R0090
Issued by

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The document is an Incident Report form for Healthcare for Homeless Veterans, designed to document critical events within 24 hours or the first working day after an incident occurs. The comprehensive form covers a wide range of potential incidents, including deaths, medical emergencies, violence, medication issues, and interactions with veterans, with checkboxes for specific incident types such as suicide, sexual assault, acts of violence, medical illnesses, and medication problems.

The related federal contract opportunity (Solicitation Number 36C26225R0090) is for Emergency Residential Beds in Service Planning Area 5 (SPA 5-LDSH), issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22. The solicitation is for Product Service Code G004, using NAICS code 624229, with a response deadline of September 25, 2025, at 10 AM Pacific Time. The solicitation is located in Long Beach, California, with no Recovery Act funds and no specific set-aside noted. The form provides a structured method for tracking and reporting critical incidents in veterans' healthcare settings, ensuring rapid communication and appropriate follow-up actions.

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ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
S02 - 36C26225R0090.docx DOCX document
ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
ATTACHMENT H - INCIDENT REPORT.docx DOCX document
ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
36C26225R0090_2.docx DOCX document
D.3 REFERENCE CONTRACT WORKSHEET.docx DOCX document
ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
ATTACHMENT E - SQUARES.pdf PDF
ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
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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 .