D5 - VCB Incident Report.docx
DOCX document 33 KB Posted
- Attached to
- G004--10 Beds Homeless Veterans - Austin, TX
- Solicitation number
- 36C25723Q1050
About this file
This document is an incident report template to be completed by providers contracted under solicitation number 36C25723Q1050 to operate a 10-bed homeless veterans facility in Austin, Texas for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17. The template requires providers to report any incidents involving veteran residents, including deaths, fires, medical emergencies, acts of violence, medication issues and other events, within 24 hours by emailing the report to the VA liaison. It requests details of the incident such as date, time, location, type of incident and circumstances, along with actions taken by the provider and names of staff contacted. Completing and signing the form are required to document incidents at the contracted facility and ensure appropriate follow up.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C25723Q1050 0001.docx | DOCX document | |
| D6 - QASP - 3 May 23 (1).pdf | ||
| 36C25723Q1050_2.docx | DOCX document | |
| D7 - INSPECTION CHECKLIST.pdf | ||
| D2 - Contractor Rules of Behavior.pdf | ||
| D3 - ADA Checklist.pdf | ||
| D1 - WD 15-5215 Rev 26 6.30.2023 (Travis).txt | TXT text file | |
| D4 - Past Performance Questionaire.docx | DOCX document |
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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 .