D.4.3_Incident Reports.docx

This is an incident report template for the Healthcare for Homeless Veterans program operated by the VA Greater Los Angeles Healthcare System. The form is designed to document and report adverse events or incidents occurring within the transitional housing services facility within 24 hours or the first working day after an incident occurs. The template captures essential incident information including the veteran's identity, project number, date, time, and specific location, along with a comprehensive categorized checklist of incident types ranging from critical events such as death, suicide, overdose, and fire to medical emergencies, safety violations including sexual assault and physical abuse, medication management issues, and behavioral incidents involving violence or abuse directed at staff or other residents.

The form documents immediate actions taken in response to incidents, such as emergency room referrals, arrests, facility departures, mental health referrals, community care coordination, case manager involvement, or program discharge. The report is filed by program staff with title and signature verification, and includes a section designated for VA liaison follow-up and disposition documentation. This template serves as a critical compliance and safety documentation tool for the 30-bed Low Demand Safe Haven facility operating under Solicitation #36C26226R0083 within the Veterans Integrated Service Network 22 structure.