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UAMS Employee/Student Injury and Incident Report
Part I

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:

Work Phone: Email Address:

Won't take your email? Click here.

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 Incident/Injury: Time of Incident/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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