The VIC (Veteran In Crisis) Report
This form can be filled out by anyone that responds to a Veteran in crisis to help them out with their difficult circumstance. None of this information is made public as we respect the privacy of our Veterans and those that respond to them. The incident report form is used by our Mental Health Team to help make a difference in the lives of our Veterans, to stay on top of issues, and see if there is some way we can make sure someone is staying on top of the crisis until our Team feels comfortable that the Veteran's crisis situation is reduced to the best of our abilities.
Date of incident
*
-
Month
-
Day
Year
Date
Duration of your dispatch to VIC (from the time you're called in to the time you separate from the VIC)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Name of OCB Rep filing out this VIC report:
*
First Name
Last Name
VIC full complete name in crisis (must have full name):
*
Prefix
First Name
Middle Name
Last Name
Suffix
VIC last 4
Location of the incident or location that you met to work with the VIC:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
List of key participants and their relationships to one another:
Complete description of the incident in chronological order:
Were you referred or contacted directly by the Veteran in crisis?
referred
directly contacted
called out by Law Enforcement
Other
Please list the referral full name if given
How were you contacted?
Phone call
Social media (e.g., facebook)
In person
email
Other
Was the crisis resolved? If resolved please explain.
Emergency action taken (e.g., did you summon police, security, and/or medical assistance?)
Yes
No
Other
Consequences (e.g., injuries; property loss or damage).
Yes
No
Other
Who did you refer the Veteran in crisis to?
*
Name of person or Organization? VSO? VA? Individual Case Worker / Battle Buddie? (list all)
What other departments or organizations were involved
ex: Police Department, Organization, VSO (be specific)
Additional file upload (optional)
Browse Files
Cancel
of
Signature
Please verify that you are human
*
Save
Submit
Print Form
Should be Empty: