	Emergency Numbers

	Emergency Flipchart

	Safety Manual

	Emergency Codes



	Online Incident/ Injury Report

	Online Hazard Report

	Main Page

	FAQ

	N95 Masks

	Our Services

	Our Staff

	Contact Us!

	Police/Safety Survey



	Training Schedule

	On-Line Training

	Training Videos

	Shots Fired Videos



	Policies/Information

	Forms

	MSDS Links

	BioHazard Waste Pickup

	Chemical Disposal

	Chemical Inventory

	Laboratory Safety Brochure

	Radiation Safety

	I-131 Pt. Release Dose Calculator

	Radioactive Decay Calculator



	UAMS Home Page

	Campus Operations

	Other Campus Operations Departments

	Site Map

University of Arkansas for Medical Sciences

Employee/Student 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 print and give to your supervisor a copy of the final form that is generated when you hit SUBMIT.
NOTE: Do not print and mail this form. Please use the SUBMIT button below to generate a completed incident report form.

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

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

First Name:

Last Name:

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 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.
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 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 needlestick or sharps injury, was the sharp medical device a "safety design" with a sheilded, recessed, retractable or blunted needle or blade?:

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

What was the employee/student doing just before the incident occurred?
(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"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

What happened? (how the injury occurred)

Primary injury type:
Area Affected:

Other injury type:
Area Affected:

Name of Supervisor/Instructor:

Supervisor/Instructor Phone No:

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 (in the First/Last Name fields).