D.8 HCHV INCIDENT REPORT.pdf
PDF 221 KB Posted
- Attached to
- G004--Evansville Heath Care for Homeless MC Veterans (HCHV) (VA-25-00078129) (VA-26-00041379)
- Solicitation number
- 36C25526R0077
About this file
This is an incident report form for the HCHV Contract Residential Care Program administered by the VA. The form must be completed and faxed to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring at a contract residential care facility serving veterans.
The form collects identifying information including the veteran's name, Social Security number, agency/facility name, and contract number. It requires documentation of incident details including date, time, and location, followed by classification of the incident type from a standardized checklist. Incident categories include death, fire, drug/police raids, suicide or suicide attempts, emergency services calls, severe medical or psychiatric emergencies, sexual assault, violence or abusive behavior involving veterans or staff, accidents, and medication problems (with subcategories for medication not sent, incorrect medication, missing medications, or adverse drug reactions). Certain incident types marked with "(N)" require national reporting. The form requires a brief narrative description of circumstances leading to the incident, witness names, outcomes, and actions taken by the contract provider. The reporting entity must provide their name, title, date, signature, and phone number. The VA HCHV Contract Residential Care Liaison completes a separate section documenting receipt of the report, distribution, follow-up requirements, and liaison signature with date.
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Text version
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 Page 2
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:
Sent to: _______________________________________________________________ Date: ________________________ Follow Up Required (if any):
VA Liaison:
Signature: _________________________________________________ Date: ___________________
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