D.8 HCHV INCIDENT REPORT.pdf

The document is an HCHV Contract Residential Care Program Incident Report form used to document and report critical incidents involving veterans in residential care facilities. The three-page form provides a structured template for reporting various types of incidents, including death, fire, drug/police events, suicide attempts, medical emergencies, sexual assault, violence, medication problems, and other significant occurrences. 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, witnesses, and actions taken. The final page is designated for VA HCHV Contract Residential Care Liaison to record additional information, follow-up requirements, and signatures, ensuring a systematic approach to tracking and addressing critical events in veteran residential care settings.