UAMS Employee / Student Injury & Incident Report

Step 1

For Patients and Visitors
All Patient and Visitor incident/injuries must be reported using the Patient Safety Event reporting program (UHC Safety Intelligence).

General Information
This Online form is usually used in the place of the multi-part Employee/Student Injury and Incident Report form. When completed, the Online Injury
and Incident form is sent to Occupational Health and Safety, Student Employee Health Services and the Office of Human Resources.

After submitting the completed form, a printable Injury and Incident form will be displayed for you to print and take with you to Student Employee Health Services (or to the Emergency Department for after-hours treatement). We also recommend printing a second copy of this form to give to your supervisor.

Note: Please complete each section of this web form. At the end, a completed Injury and Incident Report form will be available for you to print or save.

This incident/injury occurred while I was an:




Visitor / Patient

Last Name of Injured

SAP # of Injured

Or Student ID #

Date of Injury

Time of Injury


Is this incident a sharp object injury?
If needlestick or sharps injury, had the instrument involved been used on a patient?
If needlestick or sharps injury, was the sharp medical device a "safety design" with a shielded,
    recessed, retractable or blunted needle or blade?
Select type of exposure to someone else's blood or body fluids:

- Required fields