D.6 ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx

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Attached to
G004--RESIDENTIAL BEDS (WOMEN)
Solicitation number
36C26226R0013
Issued by

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The document is a Healthcare for Homeless Veterans Incident Report form designed to track and report critical events within 24 hours or the first working day after an occurrence. The comprehensive reporting template covers a wide range of incident types, including deaths, medical emergencies, acts of violence, accidents, medication issues, and interactions with veterans in residential service settings.

The related federal contract opportunity (Solicitation Number 36C26226R0013) is for Residential Service Beds specifically for Women, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22. The solicitation is located in Long Beach, California, with performance at the VA Greater Los Angeles Healthcare System, targeting NAICS code 623220. The response deadline is 11-24-2025 at 10 AM Pacific Time, with no Recovery Act funds or specific set-asides noted. The primary point of contact is Danielle Carroll, who can be reached at Danielle.Carroll4@va.gov.

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Other files

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36C26226R0013 0003.docx DOCX document
36C26226R0013 0002.docx DOCX document
36C26226R0013 0001_1.docx DOCX document
D.5 ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf PDF
D.13 ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc DOC document
D.7 ATTACHMENT D - EXTENSION REQUEST - BLANK.docx DOCX document
D.14 ATTACHMENT K - SQUARES QUICK REFERENCES.pdf PDF
D.10 ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx DOCX document
D.9 ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx XLSX spreadsheet
D.8 ATTACHMENT E - SQUARES.pdf PDF
S02 - 36C26226R0013 - NEW RESIDENTIAL SERVICES - WOMEN.pdf PDF
D.12 ATTACHMENT I - QUALITY ASSURANCE.docx DOCX document
D.4 ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf PDF
D.11 ATTACHMENT H - INCIDENT REPORT.docx DOCX document
36C26226R0013_1.docx DOCX document
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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 .