Exhibit E1_Incident ReportV2.docx
DOCX document 27 KB Posted
- Attached to
- Remote Health Readiness Program 4 (RHRP-4)
- Solicitation number
- HT001125R0020
- Issued by
-
Defense Health Agency
About this file
The document is an Incident Report template for the Remote Health Readiness Program 4 (RHRP-4) contract. The form is designed to document emergent notifications and unusual incidents involving service members, capturing comprehensive details such as personal information, event type, location, service modality (in-clinic or virtual), and incident specifics. The report includes sections for documenting injuries, first responder involvement, police notification, medical treatment, and follow-up actions.
This incident report is part of a broader solicitation (HT001125R0020) by the Defense Health Agency (DHA) for medical and dental readiness services. The contract aims to provide services to military Reserve and Active Components enrolled in TRICARE Prime Remote, DoD Service Civilians, and Department of Homeland Security members. The template serves as a standardized method for reporting and tracking incidents within the healthcare service delivery framework of the contract.
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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 Point of Contact (POC) |
| Unit UIC: |
Unit POC Name:
POC Phone:
Unit Name and Location (city, state):
POC Email:
| 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 .