D.10 INCIDENT REPORT.pdf
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- Solicitation number
- 36C24226Q0118
About this file
This is an Incident Report template for the VA New York/New Jersey Health Care Network's Homeless Care Line Veteran (HCHV) Contract Program, referenced as Attachment D.10 to RFQ 36C24226Q0118. The form is designed to be completed and submitted to the VISN Homeless Care Line Manager, Contracting Officer (COTR), and Contracting Officer within 24 hours of an incident occurrence.
The report captures essential incident information including the veteran's name, Social Security number, contracting agency/facility, and contract number. It requires documentation of the incident date, time, and location, followed by classification of the incident type, which includes categories such as death, fire, drug/police raids, suicide/suicide attempts, 911 calls, severe medical or psychiatric emergencies, sexual assault, acts of violence by or against veterans, abusive behavior by staff or veterans, accidents, and medication problems (medication not sent, incorrect medication, missing medications, or adverse drug reactions). The template also requires a brief narrative description of circumstances leading to the incident, witness names, and outcomes. Additional sections capture actions taken by both the HCHV Contract Provider and HCHV Coordinator, any required follow-up actions, and identification of VA staff contacted. The report must be completed and signed by the responsible VA staff member with date and contact information, and subsequently signed by the VA HCHV Coordinator before distribution to the VISN Contracting Officer, COTR, and VISN Homeless Care Line Manager. Incidents marked with "(N)" require national-level reporting.
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Text version
VA New York / New Jersey Health Care Network
HCHV Contract Program Incident Report
(To be completed and submitted to the VISN Homeless Care Line Manager, COTR and Contracting
Officer within 24 hours of an incident.)
Name of Veteran:
Social Security #:
Agency / Facility:
Contract #:
Description of the Incident
Date of Incident:
Time of Incident:
Location of Incident:
Type of Incident:
Death (N)
Fire (N)
Drug / Police Raid (N)
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: _________________________________________________________)
(N) = National report required) (Please continue report on next page)
ATTACHMENT D.10- INCIDENT REPORT RFQ 36C24226Q0118
Brief Description of the Incident (please include circumstances leading up to the incident, names of witnesses, if any, and outcomes; dates, and attach additional pages as needed):
Action(s) taken by HCHV Contract Provider:
Action(s) taken by HCHV Coordinator:
Follow-Up Required (if any):
Name of VA Staff Contacted:
Report Completed By
(Name and Title):
Date: __________________________
Signature: ________________________________________________________________________________
Phone: ___________________________________________________________________________________
Report filed:
A copy of this report should be sent to the VISN Contracting Officer, COTR and VISN Homeless Care Line
Manager.
VA HCHV Coordinator: ____________________________________________________________________
Signature: _________________________________________________ Date: ___________________
ATTACHMENT D.10- INCIDENT REPORT RFQ 36C24226Q0118
File details come from the government source that posted it. Updated .