VA Critical Incident REport

Veteran Critical Incident Report Form
Date Reported

MonthDayYear
Date
Date & Time of Incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Incident
Reported by Name & Position
1. Veteran/Resident Information
Full Name
Current Residence
Enter Full Address
2. Incident Type

Check all that Apply
3.4.7.1.1 Fall Incident
3.4.7.1.2 Elderly/Dependent Adult Abuse or Neglect
3.4.7.1.3. Sexual Assault
3.4.7.1.4. Fire (Veteran Involved)
3.4.7.1.5. Medical or Mental Health Emergency (911 Calls)
3.4.7.1.6. Hospitalization
3.4.7.1.7. Suicidal ideation or attempt
3.4.7.1.8. Homicidal ideation
3.4.7.1.9. Assault (of other residents or Staff)
Death
3.4.7.1.11. Infectious Control Concerns (e.g., Bed Bugs, TB, Scabies, Coronavirus)
3.4.7.1.12. Active Substance Use
3.4.7.1.13. Observation/ Possession of Weapons
3. Detailed Description of Incident (Include specific facts and observations such as events leading up to the incident individuals involved actions taken during the incident and the outcome)
4. Immediate Actions Taken:(Describe any first aid, medical treatment, or interventions provided at thetime of the incident.)
Notification
Was Nichole Moore Notified? (Sandy Finelli in Nichole's absence)
Date & Time Nichole Moore was notified

MonthDayYear
Date
Hour MinutesAM/PM Option
Was Lisa Moore Notified? (Sandy Finelli in Lisa's absence)
Date & Time Lisae Moore was notified

MonthDayYear
Date
Hour MinutesAM/PM Option
Was Emergency Services Notified?
Date & Time Emergency Services was notified

MonthDayYear
Date
Hour MinutesAM/PM Option
6. Follow-Up Actions Required: (Describe any ongoing monitoring, actions needed, or referrals to external agencies.)
7. Additional Comments:
Submitted By
Should be Empty:

1. Veteran/Resident Information

2. Incident Type

Notification