D.10 INCIDENT REPORT

ATTACHMENT D.10- INCIDENT REPORT

RFQ 36C24226Q0118

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
Medication Problem:
◊ Medication not sent
◊ Incorrect medication sent
◊ Missing medications
◊ Adverse drug reaction
(N) = National report required)

(Please continue report on next page)

ATTACHMENT D.10- INCIDENT REPORT

RFQ 36C24226Q0118

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):

Report filed:
A copy of this report should be sent to the VISN Contracting Officer, COTR and VISN Homeless Care Line Manager.