D.4.3_Incident Reports.docx

This is an Incident Report template designed for the Healthcare for Homeless Veterans program to document adverse events and situations requiring immediate reporting. The form captures incidents involving veterans in homeless services facilities, including deaths, fires, sexual assaults, medical emergencies, violence, abuse, medication issues, and accidents. Each incident must be reported within 24 hours or the first working day after the event occurs.

The form requires documentation of incident details including the veteran's name, Social Security number, facility name, project number, date, time, and specific location. Reporters must identify the incident type from a comprehensive checklist marked with priority levels (N for National reporting requirements, L for Local reporting requirements, and S for witnessed incidents). The template also requires documentation of actions taken in response, such as veteran transport to VA or non-VA facilities, referrals to mental health or community care services, arrest, program discharge, or no action taken. The report must be completed by the responding staff member with title and signature, and subsequently reviewed and followed up on by VA liaison personnel for disposition. This form supports the VA Greater Los Angeles Healthcare System's Transitional Housing Services program (Solicitation #36C26226R0083) for a 30-bed low-demand safe haven facility under Veterans Integrated Service Network 22.