D.6 HCHV Incident Report.docx
DOCX document 32 KB Posted
- Attached to
- G004--Q&A Amendment ABH 64-Bed- 2
- Solicitation number
- 36C26225R0062
About this file
This document is a Healthcare for Homeless Veterans (HCHV) Incident Report form designed to document critical events within 24 hours or by the first working day after an incident occurs. The comprehensive form provides detailed checkboxes for reporting various types of incidents, including deaths, medical emergencies, assaults, accidents, medication issues, and interactions with veterans in residential facilities.
The incident report captures key actions taken following an event, such as transporting a veteran to an emergency room, referrals to mental health services, community care follow-up, or potential discharge from a program. The form is associated with a VA Greater Los Angeles Healthcare System solicitation (Solicitation Number: 36C26225R0062) for Contracted Emergency Residential Services (CERS), specifically requesting a 64-bed emergency transitional housing tent. The form is intended to be completed by facility staff and reviewed by VA liaison personnel to track and manage critical incidents involving homeless veterans in residential care settings.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C26225R0062 0002_1.docx | DOCX document | |
| 36C26225R0062 0001.docx | DOCX document | |
| D.4 ADA accessibility checklist.pdf | ||
| 36C26225R0062_2.docx | DOCX document | |
| D.11 Quality Assurance Surveillance Plan QASP-.docx | DOCX document | |
| D.8 Appendix additional forms.pdf | ||
| D.10 Residential Treatment Exit Form Worksheet.doc | DOC document | |
| D.9 Referral Tracker Spreadsheet.xlsx | XLSX spreadsheet | |
| S02- 36C26225R0062 ABH 64 Beds- Final.pdf | ||
| D.5 Contractor Rules of Behavior Agreement Form.pdf | ||
| D.7 Request for Extension of Per Diem Form.docx | DOCX document |
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
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 .