D.4.3 HCHV INCIDENT REPORT BLANK.docx
DOCX document 32 KB Posted
- Solicitation number
- 36C26225Q0773
About this file
The document is a Healthcare for Homeless Veterans Incident Report form designed to document critical events within 24 hours or the first working day after an incident occurs. The report captures comprehensive details about various types of incidents, including deaths, medical emergencies, acts of violence, medication issues, and other significant events involving veterans receiving healthcare services.
The incident report form requires specific information such as the veteran's name, social security number, facility, date, time, and location of the incident. It provides checkboxes for multiple incident types ranging from severe medical illnesses to drug raids, sexual assaults, and staff/resident interactions. The form also tracks actions taken following an incident, such as medical referrals, emergency room visits, arrests, or program discharges, with space for additional notes and follow-up disposition by VA liaison personnel.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26225Q0773 0001_1.docx | DOCX document | |
| 36C26225Q0773_RFQ_FINAL.pdf | ||
| D.4.6 ADMISSION DENIAL REFERRAL TRACKER.xlsx | XLSX spreadsheet | |
| D.4.5 SQUARES.pdf | ||
| D.4.8 QUALITY ASSURANCE.docx | DOCX document | |
| D.4.7 RESIDENTIAL TREATMENT EXIT FORM WORKSHEET.doc | DOC document | |
| 36C26225Q0773_1.docx | DOCX document | |
| D.4.2 CONTRACTOR RULES OF BEHAVIOR AGREEMENT.pdf | ||
| D.4.4 EXTENSION EXAMPLE.docx | DOCX document | |
| D.4.1 ADA Checklist for Emergency Shelters.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 .