D.8 Incident Report Form.pdf
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- Solicitation number
- 36C25525R0011
About this file
This is a VA CRS (Contract Residential Services) Incident Report Form template that must be completed by CRS contractors and submitted to the VA CRS Liaison within 48 hours of any incident. The form is associated with Healthcare for Homeless Veterans (HCHV) Contract Emergency Residential Services (CERS) contracting opportunities.
The form requires detailed documentation including date/time of incident, names of involved parties (up to 4), supervisor notification details, other agencies contacted, witness information, staff involved, location, incident summary (including first aid details if applicable), staff intervention description, and agency follow-up actions including any improvements or training provided. The completed form requires multiple signatures including the staff member submitting the report, agency director, CRS Liaison, Contracting Officer Representative (COR), and Homeless Program Manager. The final report must be submitted to the Contracting Officer and uploaded into the eCOR file system.
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Text version
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:
File details come from the government source that posted it. Updated .