D.6 INCIDENT REPORT FORM.pdf
PDF 404 KB Posted
- Solicitation number
- 36C24226R0065
About this file
This is an Incident Report Form for the VA New York/New Jersey Health Care Network HCHV Contract Residential Care Program. The form is a template designed to document and report incidents occurring at contract residential care facilities serving veterans.
The form requires completion by contract providers within 24 hours of an incident occurring and must be faxed to the VA HCHV Contract Residential Care Liaison. Required information includes veteran identification (name and Social Security number), facility details (agency/facility name and contract number), and incident specifics (date, time, and location). The form provides checkbox categories for incident types including death, fire, drug/police raids, suicide/suicide attempts, 911 calls, severe medical or psychiatric emergencies, sexual assault, violence or abusive behavior between veterans and staff, accidents, and medication problems (medication not sent, incorrect medication, missing medications, or adverse drug reactions). Incidents marked with "(N)" require national reporting. The form requires a brief narrative description including circumstances leading to the incident, witness names, and outcomes, along with documentation of actions taken by the contract provider and the name of the VA staff member contacted. The completing provider must include their name, title, date, signature, and phone number. Page 3 is reserved for VA HCHV Contract Residential Care Liaison use to document additional information, actions taken, filing locations (nationally and locally), and any required follow-up, with signature and date from the VA liaison.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24226R0065 0002.docx | DOCX document | |
| 36C24226R0065 0001.docx | DOCX document | |
| D.8 WAGE DETERMINATION.pdf | ||
| D.2 INFORMATION SECURITY RULES OF BEHAVIOR.docx | DOCX document | |
| 36C24226R0065.docx | DOCX document | |
| D.5 HCHV INSPECTION FORM.pdf | ||
| D.7 REQUEST FOR EXTENSION OF PER DIEM FORM.pdf | ||
| D.1 QASP - Northport VA HCHV 2026.docx | DOCX document | |
| D.3 PAST PERFORMANCE REFERENCE INFORMATION.docx | DOCX document | |
| D.4 KEY PERSONNEL.docx | DOCX document |
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Text version
VA New York / New Jersey Health Care Network HCHV Contract Residential Care Program
Incident Report
(To be completed and faxed 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 (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
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:
Nationally Sent to: _______________________________________________________________
Date: ________________________
Locally Sent to: _______________________________________________________________
Date: ________________________
Follow Up Required (if any):
VA Liaison: ______________________________________________________________________________
Signature: _________________________________________________ Date: ___________________
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