D5 - VCB Incident Report.docx
DOCX document 33 KB Posted
- Attached to
- G004--14 Bed Transitional Housing & Support Services Homeless Veteran Program, Dallas, TX
- Solicitation number
- 36C25723Q1179
About this file
This document is an incident report template for residential care facilities contracted by the Valley Coastal Bend Health Care System to provide services through the Veterans Health Administration. The template requires facilities to report any incidents involving veteran residents, including deaths, fires, medical emergencies, violence, medication issues and other events, within 24 hours. Facilities must provide details of the incident such as location, witnesses, outcomes and actions taken in response. The related federal contract opportunity is for a 14-bed transitional housing and support services program in Dallas, Texas to address veteran homelessness. It is solicited by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17.
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Other files
| File | Type | Posted |
|---|---|---|
| D7 - INSPECTION CHECKLIST.pdf | ||
| D1 - WD 15-5227 Rev 19 12.27.22 (Dallas County).txt | TXT text file | |
| 36C25723Q1179_1.docx | DOCX document | |
| D6 - QASP - 3 May 23 (1).pdf | ||
| D2 - Contractor Rules of Behavior.pdf | ||
| D3 - ADA Checklist.pdf | ||
| 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 .