S02 - SOLICITATION ATTACHMENT - D.6 HEALTH CARE FOR HOMELESS VETERANS CONTRACT PROGRAM INCIDENT REPORT.pdf

VA New York / New Jersey Health Care Network

HCHV Contract Program Incident Report

(To be completed and submitted to the VISN Homeless Care Line Manager, COTR and Contracting

Officer within 24 hours of an incident.)

Name of Veteran:

Social Security #:

Agency / Facility:

Contract #:

Description of the Incident

Date of Incident:

Time of Incident:

Location of Incident:

Type of Incident:

Death (N)

Fire (N)

Drug / Police Raid (N)

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: _________________________________________________________)

(N) = National report required) (Please continue report on next page)

36C24222R0035: D.6 VA HCHV Contract Program Incident Report

Brief Description of the Incident (please include circumstances leading up to the incident, names of witnesses, if any, and outcomes; dates, and attach additional pages as needed):

Action(s) taken by HCHV Contract Provider:

Action(s) taken by HCHV Coordinator:

Follow-Up Required (if any):

Name of VA Staff Contacted:

Report Completed By

(Name and Title):

Date: __________________________

Signature: ________________________________________________________________________________

Phone: ___________________________________________________________________________________

Report filed:

A copy of this report should be sent to the VISN Contracting Officer, COTR and VISN Homeless Care Line

Manager.

VA HCHV Coordinator: ____________________________________________________________________

Signature: _________________________________________________ Date: ___________________

36C24222R0035: D.6 VA HCHV Contract Program Incident Report