ATTACHMENT H - INCIDENT REPORT.docx

36 KB Posted

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

About this file

Written by GovTribe AI ·

The document is an Incident Report template for HCHV (Homeless Commitment Housing for Veterans) Transitional Housing, designed to document and report critical incidents within 24 hours or the first working day after an event. The template comprehensively covers various incident types including death, fire, sexual assault, medical emergencies, verbal/physical violence, accidents, medication issues, and other significant events.

The incident report form requires detailed documentation such as veteran's name, facility, date/time, incident type, description of the incident, witnesses, actions taken, and interventions. The form provides multiple checkboxes for reporting incidents ranging from medical emergencies to arrests, veteran departures, referrals, and follow-up actions. This template appears directly related to the associated federal contract opportunity (Solicitation Number 36C26225R0090) for Emergency Residential Beds through the Department of Veterans Affairs Veterans Health Administration, specifically for Veterans Integrated Service Network 22 located in Long Beach, California.

View the file

Other files

File Type Posted
ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx DOCX document
ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
S02 - 36C26225R0090.docx DOCX document
ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
D.3 REFERENCE CONTRACT WORKSHEET.docx DOCX document
36C26225R0090_2.docx DOCX document
ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
ATTACHMENT E - SQUARES.pdf PDF
ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
Show all 13

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 .