D.5 HCHV CONTRACT PROGRAM INCIDENT REPORT.pdf
PDF 638 KB Posted
- Solicitation number
- 36C24223R0004
About this file
This document is an incident report form for homeless veterans' housing contracts within the VA New York/New Jersey Health Care Network. The form requires reporting within 24 hours various incidents such as deaths, fires, drug raids, suicides or attempts, medical emergencies, acts of violence, accidents, and medication issues. It requests details of the incident, actions taken by the provider and coordinator, and any required follow up. A copy must be sent to the VISN Contracting Officer, COTR, and Homeless Care Line Manager.
The related federal contract opportunity is a solicitation for low demand safe haven housing and services for homeless veterans in Canandaigua, New York. Solicitation number 36C24223R0004 is for the Department of Veterans Affairs Veterans Health Administration VISN 2. The document provides information on an incident reporting requirement for homeless veterans housing contracts within the specified network but does not include pricing, response dates, products/services, or other contract details.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24223R0004 0001.docx | DOCX document | |
| D.6 HCHV CR REQUEST FOR EXTENSION OF PER DIEM.pdf | ||
| D.3 HCHV CONTRACT RESIDENT FACILITY INSPECTION PACKET.pdf | ||
| D.4 HCHV NOTICE OF NEW CONTRACT FORM.pdf | ||
| 36C24223R0004_2.docx | DOCX document | |
| D.2 HEALTH CARE FOR HOMELESS VETERANS CONTRACT RESIDENTIAL SERVICES PROGRAM _ VHA DIRECTIVE 1162.04.docx | DOCX document |
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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
File details come from the government source that posted it. Updated .