D.5 HCHV CONTRACT PROGRAM INCIDENT REPORT.pdf
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- Solicitation number
- 36C24223R0003
About this file
This document is an incident report form for residential services contracted through the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 2. The form requires reporting of incidents involving veteran residents within 24 hours to the VISN Homeless Care Line Manager, Contracting Officer's Technical Representative, and Contracting Officer. Reportable incidents include death, fires, drug raids, suicide attempts, medical emergencies, psychiatric emergencies, sexual assault, violence, abuse, accidents, and medication issues. The form requests details of the incident such as location, witnesses, actions taken by the contract provider and VA coordinator, and any required follow up. It is to be completed and sent electronically to the specified VA officials and filed by the contract provider.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24223R0003 0003.docx | DOCX document | |
| 36C24223R0003 0002.docx | DOCX document | |
| 36C24223R0003 0001.docx | DOCX document | |
| 36C24223R0003_1.docx | DOCX document | |
| D.6 HCHV CR REQUEST FOR EXTENSION OF PER DIEM.pdf | ||
| D.2 HEALTH CARE FOR HOMELESS VETERANS CONTRACT RESIDENTIAL SERVICES PROGRAM _ VHA DIRECTIVE 1162.04.docx | DOCX document | |
| D.3 HCHV CONTRACT RESIDENT FACILITY INSPECTION PACKET.pdf | ||
| D.4 HCHV NOTICE OF NEW CONTRACT FORM.pdf |
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Text version
VA New York / New Jersey Health Care Network
HCHV Contract Program Incident Report
(To be completed and submitted to the VISN Homeless Care Line Manager, COTR and Contracting
Officer within 24 hours of an incident.)
Name of Veteran:
Social Security #:
Agency / Facility:
Contract #:
Description of the Incident
Date of Incident:
Time of Incident:
Location of Incident:
Type of Incident:
Death (N)
Fire (N)
Drug / Police Raid (N)
Suicide / Suicide Attempt
911 Call (Police / Fire Dept. / Paramedics / Other)
Severe Medical Illness / Emergency
Severe Psychiatric Illness / Emergency
Sexual Assault
Act of violence by veteran against other resident(s) or staff
Abusive behavior by veteran against staff
Act of violence by other resident(s) or staff against veteran
Abusive behavior by staff against veteran
Accident (Specify: ______________________________________________________)
Medication Problem:
◊ Medication not sent
◊ Incorrect medication sent
◊ Missing medications
◊ Adverse drug reaction
Other (Specify: _________________________________________________________)
(N) = National report required) (Please continue report on next page)
D.5 VA HCHV Contract Program Incident Report
Brief Description of the Incident (please include circumstances leading up to the incident, names of witnesses, if any, and outcomes; dates, and attach additional pages as needed):
Action(s) taken by HCHV Contract Provider:
Action(s) taken by HCHV Coordinator:
Follow-Up Required (if any):
Name of VA Staff Contacted:
Report Completed By
(Name and Title):
Date: __________________________
Signature: ________________________________________________________________________________
Phone: ___________________________________________________________________________________
Report filed:
A copy of this report should be sent to the VISN Contracting Officer, COTR and VISN Homeless Care Line
Manager.
VA HCHV Coordinator: ____________________________________________________________________
Signature: _________________________________________________ Date: ___________________
36C24222R0035: D.6 VA HCHV Contract Program Incident Report
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