D.3.3 HCHV INCIDENT REPORT BLANK.docx
DOCX document 32 KB Posted
- Solicitation number
- 36C26224Q1360
About this file
This document is a Healthcare for Homeless Veterans Incident Report form used to report incidents involving veterans receiving services. The form includes fields to capture details such as the veteran's name, the facility, the type of incident (e.g. death, sexual assault, medication issues), actions taken (e.g. sending the veteran to the VA emergency room, discharging the veteran), and contact information for the person filing the report.
The related federal contract opportunity is a Request for Quote (RFQ) from the Department of Veterans Affairs, Network Contract Office 22, seeking contractors to provide housing and recuperative care services for up to 10 male veterans within a 15-mile radius of the West Los Angeles Veterans Administration Medical Center. This is a Firm Fixed Price, Single-Award Indefinite Delivery Indefinite Quantity contract with a period of five one-year ordering periods. Responses are due by 10:00AM Pacific Daylight Time on August 30, 2024. The Point of Contact is Ben Bayoneta, Contract Specialist.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26224Q1360 0002_1.docx | DOCX document | |
| 36C26224Q1360 0001_1.docx | DOCX document | |
| 36C26224Q1360_FINAL.docx | DOCX document | |
| D.3.2 CONTRACTOR RULES OF BEHAVIOR AGREEMENT.pdf | ||
| 36C26224Q1360_1.docx | DOCX document | |
| D.2 Price Worksheet.xlsx | XLSX spreadsheet | |
| D.3 Reference Contract Worksheet.docx | DOCX document | |
| D.3.6 ADMISSION DENIAL REFERRAL TRACKER.xlsx | XLSX spreadsheet | |
| D.3.1 ADA Checklist for Emergency Shelters.pdf | ||
| D.3.4 EXTENSION EXAMPLE.docx | DOCX document | |
| D.3.5 SQUARES.pdf |
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Text version
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 .