D.6 HCHV Contract Residential Care Program Incident Report.docx

HCHV Contract Residential Care Program Incident Report (To be completed and forwarded to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring.)

Name of Veteran: ________________________________________________________________________

Social Security No.: ________________________________________________________________________

Agency / Facility: ________________________________________________________________________

Contract No.: _________________________________________________________________________

Description of the Incident

Date of Incident: ________________________Time of Incident: __________________

Location of Incident: _______________________________________________________________________

Type of Incident:

Death Fire Drug / Police Raid Suicide / Suicide Attempt Homicidal Ideations 911 call (police/fire dept./paramedics/other) Drug overdose Severe medical illness / emergency; severe psychiatric illness / emergency Sexual assault Act of violence by Veteran against other(s) Abusive behavior by Veteran against staff Abusive behavior by staff against veteran Accident (Specify: ______________________________________________________) Medication problems or adverse drug reactions; or other untoward events.

Infectious Disease Concerns and any Infestations of rodents/bugs Observations/Possessions of man-made/commercial weapons Medication Problem Other (Specify: _________________________________________________________) Brief Description of the Incident (please include circumstances leading up to the incident, names of witnesses, if any, and outcomes; attach additional pages as needed):

Action(s) taken by Contract Provider:

Name of VA Staff Contacted: ________________________________________________________________ Report Completed By: ______________________________________________________________________ Title: _______________________________________________ Date: ______________________ Signature: ________________________________________________________________________________ Phone: ___________________________________________________________________________________ For VA HCHV Contract Residential Care Liaison Additional information and actions taken including date(s):

Report filed:

Sent to: _______________________________________________________________ Date: ________________________ Follow Up Required (if any):

VA Liaison: ______________________________________________________________________________ Signature: _________________________________________________ Date: ___________________