D.6 INCIDENT REPORT FORM.pdf
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- Solicitation number
- 36C24226R0075
About this file
This is an Incident Report Form (D.6) for the VA New York/New Jersey Health Care Network HCHV Contract Residential Care Program. The form is designed to document and report incidents occurring at contract residential care facilities housing veterans and must be completed and faxed to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring.
The form requires reporting of veteran information (name, social security number, agency/facility, and contract number) and detailed incident documentation including date, time, and location. Reportable incident types include 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 or among residents, accidents, and medication problems (medication not sent, incorrect medication sent, missing medications, or adverse drug reactions). Certain incident types marked with "(N)" require national reporting. The form includes sections for a brief narrative description of circumstances leading to the incident, witness names, and outcomes; documentation of actions taken by the contract provider; and identification of VA staff contacted. The reporting provider must sign and date the form with their title and phone number. Page three is reserved for VA HCHV Contract Residential Care Liaison use to document additional information, actions taken with dates, whether the report was filed nationally or locally with corresponding dates, follow-up requirements, and liaison certification.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24226R0075 0001.pdf | ||
| D.7 WAGE DETERMINATION.pdf | ||
| D.4 HCHV INSPECTION FORM.pdf | ||
| D.8 BRONX MAP.pdf | ||
| D.5 REQUEST FOR EXTENSION OF PER DIEM FORM.pdf | ||
| D.3 KEY PERSONNEL.docx | DOCX document | |
| D.1 INFORMATION SECURITY RULES OF BEHAVIOR.docx | DOCX document | |
| 36C24226R0075_1.docx | DOCX document | |
| D.2 PAST PERFORMANCE REFERENCE INFORMATION.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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