D5 - VCB Incident Report.docx
DOCX document 33 KB Posted
- Attached to
- Austin / Waco TX Transitional Housing Federal contract opportunity
- Solicitation number
- 36C25723Q0941
About this file
This document is an incident report template to be completed by residential care facilities contracted by the Department of Veterans Affairs under solicitation number 36C25723Q0941 for transitional housing services in Austin and Waco, Texas. The template requires facilities to report any incidents involving veteran residents, such as deaths, fires, medical emergencies, violence, medication issues or other events, within 24 hours by emailing the report to the VA liaison. It collects details of the incident such as date, time, location, type of incident, description of circumstances and outcomes, as well as actions taken by the contract provider in response. Contact information is also requested for the VA staff member notified and the person completing the report.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| D1.1 - WD 15-5261 Rev 21 7.12.2023 (McLennan).txt | TXT text file | |
| D1 - WD 15-5215 Rev 26 6.30.2023 (Travis).txt | TXT text file | |
| D6 - QASP - 3 May 23 (1).pdf | ||
| D2 - Contractor Rules of Behavior.pdf | ||
| D4 - Past Performance Questionaire.docx | DOCX document | |
| D3 - ADA Checklist (2).pdf | ||
| D7 - INSPECTION CHECKLIST (1).pdf |
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Text version
Valley Coastal Bend Health Care System 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: )
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:
File details come from the government source that posted it. Updated .