D.8 INCIDENT REPORT FORM.pdf

VA CRS Incident Report Form

CRS Contractor to complete form and submit to VA CRS Liaison within 48 hours of incident.

Date of incident: Time of incident:

Name of 1st party: Name of 2nd party:

Name of 3rd party: Name of 4th party:

Name of supervisor notified: Other agencies contacted:

Date & time supervisor notified: Date & time VA notified:

Names of other witnesses:

Name(s) of staff involved:

Address and location of incident:

Summary of incident (if first aid rendered – give specific details):

Staff intervention at time of incident:

How did the agency follow-up on the report? Be sure to include any actions for improvement or training and debriefing offered to staff or Veterans:

Report submitted by:

VA review & recommendations:

CRS Liaison name:

CRS Liaison signature:

COR name:

COR signature:

Homeless program manager name:

Homeless program manager signature:

Report should be submitted to the Contracting Officer and uploaded into the e-

COR file.

Name & title of staff submitting report:

Signature of staff submitting report:

Name & title of agency director:

Signature of agency director: