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

Minor InjurySerious Injury
3.4.7.1.2 Elderly/Dependent Adult Abuse or Neglect

Yes
3.4.7.1.3. Sexual Assault

Yes
3.4.7.1.4. Fire (Veteran Involved)

Yes
3.4.7.1.5. Medical or Mental Health Emergency (911 Calls)

MedicalMental Health
3.4.7.1.6. Hospitalization

Yes
3.4.7.1.7. Suicidal ideation or attempt

Yes
3.4.7.1.8. Homicidal ideation

Yes
3.4.7.1.9. Assault (of other residents or Staff)

Yes
Death

AccidentialNatural Causes
3.4.7.1.11. Infectious Control Concerns (e.g., Bed Bugs, TB, Scabies, Coronavirus)

Yes
3.4.7.1.12. Active Substance Use

Yes
3.4.7.1.13. Observation/ Possession of Weapons

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
Was Nichole Moore Notified? (Sandy Finelli in Nichole's absence)*

YesNo
Date & Time Nichole Moore was notified*

MonthDayYear
Date
Hour MinutesAM/PM Option
Was Lisa Moore Notified? (Sandy Finelli in Lisa's absence)*

YesNo
Date & Time Lisae Moore was notified*

MonthDayYear
Date
Hour MinutesAM/PM Option
Was Emergency Services Notified?*

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

2. Incident Type

Notification