D.3 VA CRS Incident Report Form.pdf
PDF 136 KB Posted
- Attached to
- G004--EMERGENCY CONTRACT SERVICES_HEALTH CARE HOMELESS VETERAN ST. LOUIS (VA-25-00001620)
- Solicitation number
- 36C25525Q0004
About this file
This is a VA CRS (Community Residential Services) Incident Report Form that must be completed by CRS contractors and submitted to the VA CRS Liaison within 48 hours of any incident. The form captures comprehensive incident details including date/time of occurrence, involved parties (up to 4), supervisor notifications, other agencies contacted, witness information, staff involvement, location, and a detailed incident summary with specific first aid details if rendered.
The form requires multiple levels of review and approval, including signatures from the CRS Liaison, Contracting Officer's Representative (COR), and Homeless Program Manager. It includes sections for documenting staff intervention during the incident, agency follow-up actions, improvement measures, and training/debriefing provided to staff or veterans. The completed report must be submitted to the Contracting Officer and uploaded into the eCOR file system, maintaining accountability and documentation of incidents within the VA healthcare system for homeless veterans.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
VA CRS Incident Report Form
CRS Contractor to complete form and submit to VA CRS Liaison within 48 hours of incident.
Date of incident: Time of incident:
Name of 1st party: Name of 2nd party:
Name of 3rd party: Name of 4th party:
Name of supervisor notified: Other agencies contacted:
Date & time supervisor notified: Date & time VA notified:
Names of other witnesses:
Name(s) of staff involved:
Address and location of incident:
Summary of incident (if first aid rendered – give specific details):
Staff intervention at time of incident:
How did the agency follow-up on the report? Be sure to include any actions for improvement or training and debriefing offered to staff or Veterans:
Report submitted by:
VA review & recommendations:
CRS Liaison name:
CRS Liaison signature:
COR name:
COR signature:
Homeless program manager name:
Homeless program manager signature:
Report should be submitted to the Contracting Officer and uploaded into the e- COR file.
Name & title of staff submitting report:
Signature of staff submitting report:
Name & title of agency director:
Signature of agency director:
File details come from the government source that posted it. Updated .