Patient and Visitor incident/injuries must be reported using the Patient Safety Net program.
Look for the UHC/PSN icon on your desktop.

This form can be used in the place of the multi-part Employee/Student Injury and Incident Report form. The completed form will be sent to O H & S, Student Employee Health Services, and Human Resources.

After submission of this form, 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 print and give to your supervisor a copy of the final form that is generated when you click the SUBMIT button.

NOTE: Do not print and mail this form. Please use the Submit button below to generate a completed Injury and Incident Report form.