Incident Report Durham CERS.pdf
PDF 165 KB Posted
- Attached to
- G004--New Transitional Housing Contract
- Solicitation number
- 36C24626Q0385
About this file
This is an Incident Report Form for the Durham VA Health Care System's Contract Residential Care Program. The form is designed to document and report incidents occurring at contract residential care facilities serving veterans within 24 hours of occurrence. The form requires identification of the veteran involved (name and Social Security number), the contracting agency/facility, and the specific contract number associated with the placement.
The form captures detailed incident information including date, time, and location, followed by incident type classification from a predefined list that includes death, fire, drug/police raids, suicide or suicide attempts, 911 calls, severe medical or psychiatric emergencies, sexual assault, acts of violence or abusive behavior by or against veterans, and accidents. The reporting contract provider must submit a brief narrative description encompassing circumstances leading to the incident, witness names, and outcomes, along with documentation of actions taken in response. The form requires contact information for the VA staff member notified and completion details including the reporting party's name, title, date, signature, and phone number. A separate section for the VA HCHV Contract Residential Care Liaison documents additional actions taken, routing information (whether sent nationally or locally with corresponding dates), and any required follow-up actions, signed by the VA liaison with date of completion.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24626Q0385 0002.docx | DOCX document | |
| 36C24626Q0385 0001.docx | DOCX document | |
| 36C24626Q0385_1.docx | DOCX document |
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Text version
Durham VA Health Care System HCHV
Contract Residential Care Program Incident
Report
(To be completed and faxed to the VA HCHV Contract Residential Care Liaison within 24 hours of an incident occurring.)
Name of Veteran: __________________________________________________________________________
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
Drug / Police Raid
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:
Other (Specify:_________________________________________________________)
INCIDENT REPORT FORM
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: ___________________________________________________________________________________
For VA HCHV Contract Residential Care Liaison
Additional information and actions taken including date(s):
Report filed:
Nationally Sent to: _______________________________________________________________
Date: ________________________
Locally Sent to: _______________________________________________________________
Date: ________________________
Follow Up Required (if any):
VA Liaison: ______________________________________________________________________________
Signature: _________________________________________________ Date: ___________________
| Name of Veteran: |
| Social Security No: |
| Agency Facility: |
| Contract No: |
| Date of Incident: |
| Time of Incident: |
| Location of Incident: |
| Death N: Off |
| Fire N: Off |
| Drug Police Raid N: Off |
| Suicide Suicide Attempt: Off |
| 911 Call Police Fire Dept Paramedics Other: Off |
| Severe Medical Illness Emergency: Off |
| Severe Psychiatric Illness Emergency: Off |
| Sexual Assault: Off |
| Act of violence by veteran against other residents or staff: Off |
| Abusive behavior by veteran against staff: Off |
| Act of violence by other residents or staff against veteran: Off |
| Abusive behavior by staff against veteran: Off |
| Accident Specify: Off |
| Medication Problem: Off |
| Other Specify: Off |
| undefined: |
| Medication not sent: Off |
| Incorrect medication sent: Off |
| Missing medications: Off |
| Adverse drug reaction: Off |
| undefined_2: |
| Name of VA Staff Contacted: |
| Report Completed By: |
| Title: |
| Date: |
| Phone: |
| Nationally: Off |
| Locally: Off |
| Sent to: |
| Date_2: |
| Sent to_2: |
| Date_3: |
| VA Liaison: |
| Date_4: |
| Text1: |
| Text2: |
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