Exhibit E1_Incident Report.docx
DOCX document 26 KB Posted
- Attached to
- Remote Health Readiness Program 4 (RHRP-4) Federal contract opportunity
- Solicitation number
- HT001125R0020
- Issued by
- Defense Health Agency
About this file
This is an Incident Report template (Exhibit E1) associated with the Remote Health Readiness Program 4 (RHRP-4) contract. The template is designed to document both Emergent Notifications and Unusual Incident Reports involving Service Members under the RHRP-4 program.
The form captures comprehensive incident details including Service Member information (name, contact details, rank, DoD ID, unit information), clinician information, witness details, and incident specifics. It requires documentation of event type (physical, behavioral health, or both), injury details, first responder involvement, and treatment status. The form also records the incident's date, time, location, and service modality (in-clinic, virtual, group event, or other), along with immediate actions taken and follow-up notes. This template appears to be part of the Defense Health Agency's documentation requirements for tracking and reporting incidents within their medical and dental readiness services program.
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Text version
| CUI/Privacy Act/HIPAA Statement | RHRP-4 PWS Exhibit E1_ Incident Report | |
| INCIDENT REPORT |
General Information This form is to be used to document any Emergent Notification and Unusual Incident Reports. Please select the appropriate documentation type below.
☐ Emergent Notification ☐ Unusual Incident Report (UIR)
Who
Service Member
Name:
Home Address:
Phone:
Email:
Rank:
Service Component:
DoD ID:
Unit Name and Location (city, state):
| Clinician |
| Name: |
Phone:
Email:
| Reporting Individual |
| Name: |
Email:
Witness(es) – (N/A if none) Name:
Phone Email:
What
Describe the Event
| Event Type |
| ☐ Physical ☐ Behavioral Health ☐ Both |
Emergent? ☐ Yes ☐ No
| Injuries |
| Name(s) of Injured: |
Description of Injuries:
| First Responders |
| Police Notified ☐ Yes ☐ No |
| Police Report Filed ☐ Yes ☐ No |
Medical Treatment ☐ Yes ☐No ☐ Refused
When
Date & Time of the Incident
Today’s Date
Where
Location of the Incident
| Modality of Service |
| ☐ In-Clinic ☐ Virtual ☐ Group Event ☐ Other (Describe) |
Immediate Actions Taken
Follow Up
Notes
File details come from the government source that posted it. Updated .