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University of Arkansas for Medical Sciences

Employee/Student/Visitor Injury and Incident Report


This online form can be used in place of the multi-part Employee/Student/Visitor Injury and Incident Report form. This online form will submit electronically to Occupational Health and Safety, Student Employee Health Services, and Human Resources.
After submission, a printable Injury and Incident form will be displayed that you may print and take with you to Student Employee Health Services (or to the Emergency Department for after-hours treatement).
You should also give a copy of the printed form to your supervisor.

This incident/injury occurred while I was an: Employee     Student     Visitor

First Name:

Last Name:

Job Title:

Work Phone:

Email Address:

UAMS ID Badge Barcode Number or SAP ID Number:

This is the number beneath the barcode on your UAMS Student or Employee ID Badge.
Your SAP ID number is found in the upper right hand corner of your UAMS ID.

Date of Accident/Injury:

Time of Accident/Injury:

Building:

Floor:     Room / Area:

Other Location Information:

Accident Type:

Name of Object or Substance which directly injured employee/student:

If needlestick or sharps injury, had the instrument involved been used on a patient?:

If injury involves exposure to blood or body fluids, select the type of exposure:

Description of Accident/Injury/Exposure:

Name of Supervisor/Instructor:

Supervisor/Instructor Phone No:

Witness Name:

Witness Address:

By submitting this form, you are certifying that you are the individual named above (in the First/Last Name fields).