ATTACHMENT H - 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 an Incident Report template for HCHV (Healthcare for Homeless Veterans) Transitional Housing, designed to document critical events within 24 hours or by the first working day after an incident occurs. The comprehensive form allows detailed reporting of various incident types, including deaths, fires, sexual assaults, medical incidents, violence, accidents, medication issues, and other significant events. The report requires documentation of the veteran's information, incident details, witnessing, actions taken, interventions, and follow-up, with sections for reporting staff to complete their contact information and signatures, and a designated area for VA liaison follow-up and final disposition.

The related federal contract opportunity (Solicitation Number: 36C26225R0075) is for New Residential Services Beds specifically for Women, issued by the Department of Veterans Affairs Network Contracting Office in Long Beach, California. The solicitation is classified under 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 includes multiple attachments such as ADA accessibility checklists, contract behavior agreements, residential treatment referral worksheets, and quality assurance documents, indicating a comprehensive approach to providing residential services for women veterans.

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Other files

File Type Posted
ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
36C26225R0075_2.docx DOCX document
ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
D.3 REFERENCE CONTRACT WORKSHEET.docx DOCX document
S02 - 36C26225R0075 - RESIDENTIAL SERVICES updated 02.pdf PDF
ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
ATTACHMENT E - SQUARES.pdf PDF
ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx DOCX document
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HCHV Transitional Housing 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)|_| 911 call (police/fire department/paramedic)
|_| Severe medical illness (L)|_| Other medical illness
|_| Act of Verbal 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:

Brief description of the incident:

Was incident seen? |_| No |_| Yes, by whom?

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:

Intervention:

Telephone to VA (state name)

|_| Liaison |_| Program coordinator |_| Other (specify reason) Send e-mail to Liaison

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 .