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: 205 S. Cedar318 S. Pine601 S. CedarAdministration BuildingAHEC - DeltaAHEC - Fort SmithAHEC - North CentralAHEC - NortheastAHEC - NorthwestAHEC - Pine BluffAHEC - SouthAHEC - SouthwestArkansas Children`s HospitalBaptist Student Union BuildingBarton Research BuildingBiohazard Area (on F level of Parking Deck)Biomedical Research Building 1Biomedical Research Building 2BioVentures BuildingBlanford BuildingBoiler HouseBookstoreCancer Institute (ACRC)College of Public Health BuildingCommunity Womens Health ClinicDistribution CenterEducation Building WestEducation South (KARN Bldg)Educational Building IIEducational Building IIIFamily Medical CenterFreeway Medical CenterGroundsHead Start CentersInformation Technology (Computer Building)Institute on AgingJack Stephens Neurosciences BuildingJones Eye InstituteKids FirstMagnetic Resonance Imaging/Gamma KnifeMediplex ApartmentsOtherOutpatient Center 1Outpatient Center 2Outpatient Center Administration (5th and Cedar)Outpatient Diagnostic CenterPaint Shop / Flammable Storage BuildingParking Deck - EastParking Deck - NorthParking Deck - SouthPET BuildingPhysical PlantPsychiatric Research Institute BuildingRadiation Oncology Building (CARTI)Residence Hall Admin BuildingResidence Hall NorthResidence Hall SouthShorey BuildingSturgis Building (at ACH)Substance Abuse Treatment ClinicTrailer #1 - Elm StreetTrailer #2 - behind Family Medical CenterTrailer #3 - behind Family Medical CenterTrailer #4 - MRI Parking LotTrailer #5 - East of Outpatient Parking DeckUniversity HospitalUniversity TowerVA HospitalWard Clinical TowerWest Central Energy PlantWestmark BuildingWestside Building (at ACH)

Floor:     Room / Area:

Other Location Information:

Accident Type: Fall from ElevationFall on same levelStruck againstStruck byCaught In/Under/BetweenRubbed or AbradedBodily ReactionOverexertionContact with electrical currentContact with radiations/caustics/toxic and noxious substancesContact with temperature extremesMotor vehicle accidentOther

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

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

If injury involves exposure to blood or body fluids, select the type of exposure: Skin ExposureMucous Membrane ExposureNeedle stick or sharps injury

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).