Type of Hazard (Select appropriate radio button):
       Fire           Health           Mechanical           Electrical           Radiation
       Chemical / Biological            Other

Building: 205 S. Cedar318 S. Pine601 S. CedarAdmin Residence HallAdmin West BuildingAHEC - DeltaAHEC - Fort SmithAHEC - North CentralAHEC - NortheastAHEC - NorthwestAHEC - Pine BluffAHEC - SouthAHEC - SouthwestArkansas BioVenturesArkansas Children`s HospitalBaptist Student Union BuildingBarton ResearchBiohazard Area (on F level of Parking Deck)Biomedical Research Center IBiomedical Research Center IIBlanford BuildingBook StoreCentral BuildingCHRP Building 2CHRP Building 3CHRP Building 4CHRP Building 4ACHRP Building 5CHRP Building 5ACHRP Building 6ACollege of Public HealthCommunity Women`s ClinicComputing ServicesDistribution CenterDonald W. Reynolds Institute on AgingE WingEducational Building IIEducational Building IIIEducational Building SouthFamily & Preventive MedicineFreeway Medical TowerGroundsHead Start CentersHospitalI. Dodd Wilson Education BuildingJackson T. Stephens Spine InstituteJones Eye InstituteKids FirstMagnetic Resonance Imaging/Gamma KnifeMediplex ApartmentsNorth Residence HallOtherOutpatient Care Center 1Outpatient Care Center 2Outpatient Center Administration (5th and Cedar)Outpatient Diagnostic CenterPaint FlammableParking Deck 1Parking Deck 2Parking Deck 3PET BuildingPhysical PlantPower PlantPrimary Data CenterPsychiatric Research InstituteRadiology/Oncology Building (CARTI)South Residence HallSturgis Building (at ACH)Substance Abuse Treatment Center (SATC)Trailer 1 - Elm StreetTrailer 2 - behind Family Medical CenterTrailer 3 - behind Family Medical CenterTrailer 4 - MRI Parking LotTrailer 5 - East of Outpatient Parking DeckUniversity TowerVA HospitalWest Central Energy PlantWestmarkWestside Building (at ACH)Winston K. Shorey BuildingWinthrop P. Rockefeller Cancer Institute

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Location and Description of Hazard (Date, Time, Summary):
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First Name:

Last Name:

Work Phone:

Email Address:

UAMS ID Badge Barcode Number 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.

By submitting this form, you are certifying that you are the individual named above.