D.8 HCHV INCIDENT REPORT.pdf

This document is an HCHV Contract Residential Care Program Incident Report form designed for reporting critical incidents involving veterans in residential care facilities. The three-page form provides a structured template for documenting various types of incidents, including death, fires, drug/police issues, suicide attempts, medical emergencies, sexual assault, violent acts, medication problems, and other significant events. The form requires detailed information such as the veteran's name, social security number, agency/facility, contract number, date and time of incident, location, and a comprehensive description of the incident, including circumstances, witnesses, and actions taken by contract providers. The report must be completed and faxed to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring, and includes sections for VA staff contact information and follow-up actions.