For Patients and Visitors
All Patient and Visitor incident/injuries must be reported using the Patient Safety Event reporting program (UHC Safety Intelligence).
This Online form is usually used in the place of the multi-part Employee/Student Injury and Incident Report form. When completed, the Online Injuryand 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
∗ - Required fields