D5 - Incident Report.docx

HCHV Contract Residential Care Program Incident Report

(To be completed and e-mailed to the VA Liaison within 24 hours of an incident occurring.)

Name of Veteran:

Last Four of Social Security No.:

Agency / Facility: Contract No.:

Description of the Incident

Date of Incident: Time of Incident:

Location of Incident:

Type of Incident:

|_| Death |_| Fire |_| 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: )

D5 Incident Report

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: