D.11 ATTACHMENT H - INCIDENT REPORT.docx

36 KB Posted

Attached to
G004--RESIDENTIAL BEDS (WOMEN)
Solicitation number
36C26226R0013
Issued by

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The file "D.11 ATTACHMENT H - INCIDENT REPORT.docx" appears to be an incident reporting document related to a Department of Veterans Affairs solicitation for Residential Service Beds for Women. The solicitation (Number 36C26226R0013) is issued by the VA Greater Los Angeles Healthcare System's Network Contracting Office located in Long Beach, California, with a response deadline of November 24, 2025 at 10 AM Pacific Time. The procurement is classified under NAICS code 623220 and Product Service Code G004, targeting residential care facilities for women veterans. The solicitation does not indicate any specific set-asides and is not utilizing Recovery Act funds. The primary point of contact is Danielle Carroll, who can be reached at Danielle.Carroll4@va.gov, with the place of performance located at 11301 Wilshire Blvd, Los Angeles, CA 90073.

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Other files

File Type Posted
36C26226R0013 0003.docx DOCX document
36C26226R0013 0002.docx DOCX document
36C26226R0013 0001_1.docx DOCX document
D.12 ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
D.4 ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
36C26226R0013_1.docx DOCX document
D.13 ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
D.9 ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
D.7 ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
D.5 ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
D.14 ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
D.10 ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
D.8 ATTACHMENT E - SQUARES.pdf PDF
D.6 ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx DOCX document
S02 - 36C26226R0013 - NEW RESIDENTIAL SERVICES - WOMEN.pdf PDF
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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 .