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
Minor InjurySerious Injury
Yes
Yes
Yes
MedicalMental Health
Yes
Yes
Yes
Yes
AccidentialNatural Causes
Yes
Yes
Yes
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
YesNo
Date & Time Nichole Moore was notified*

MonthDayYear
Date
Hour MinutesAM/PM Option
YesNo
Date & Time Lisae Moore was notified*

MonthDayYear
Date
Hour MinutesAM/PM Option
YesNo
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