UAMS Employee/Student Injury Incident Report

Sat, May 26, 2012

UAMS Employee/Student Injury and Incident Report

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.

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

First Name of Injured Employee/Student:

Last Name of Injured Employee/Student:

Job Title:

Choose the category which best describes the employee's regular type of job or work:

Work Phone: Email Address:

UAMS ID Badge Barcode # or SAP ID #:

The Badge ID # is located beneath the barcode on your UAMS Student or Employee ID Badge.
Your SAP ID # is found in the upper right hand corner of your UAMS ID.
Your First Name and Last Name must match the name listed for you in SAP.

Date of Accident/Injury: Time of Accident/Injury:

Time employee began work: Event occurred:

Building: Floor:

Room / Area: Other Location Info:

Accident Type:

Name of Object or Substance which directly injured employee/student: (limit 255 characters)

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 sheilded, recessed, retractable or blunted needle or blade?:

Did this incident involve exposure to someone else's blood or body fluids?

If injury involves exposure to someone else's blood or body fluids, select the type of exposure:

What was the employee/student doing just before the incident occurred? (limit 255 characters)
(Describe the activity as well as the tools, equipment, or material the employee was using. Be specific.)
Examples: "climbing a ladder while carrying roofing materials"; "daily computer key-entry."

What happened? (how the injury occurred) (limit 255 characters)

Primary injury type:
Area Affected:

Other injury type:
Area Affected:

Name of Supervisor/Instructor:
Supervisor/Instructor Phone No:
Supervisor/Instructor E-mail:
Won't take your email? Click here.

Witness Name:

Witness Address:

At this time I DID DID NOT see a doctor/nurse about this injury.

By submitting this form, you are certifying that you are the individual named above.
(The name typed into First and Last Name fields).

University of Arkansas for Medical Sciences
Occupational Health & Safety, Slot 617
Central Building, Ground Floor, Room # G154
4301 W. Markham St., Little Rock, AR 72205

Office, Call 501-686-5536
Fax 501-296-1339
Business Hours 8:00 am - 4:30 pm, Monday - Friday

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