ENHS | Accident Reporting Form

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If you believe there is an immediate danger to life or health call 911 or University Police at (479) 575-2222. Report motor vehicle accidents to University Police at (479) 575-2222. Report threats of violence, sexual misconduct, and other concerns through the report.uark.edu website.

This form will alert the Environmental Health and Safety Office (ENHS) of injuries, accidental incidents, and near miss events on campus to identify and resolve campus concerns. This form is in reference to VCFA Policy 700.2.

PLEASE NOTE: Any event involving workplace injuries must be reported to the Company Nurse Hotline (1-855-339-1893) to be considered for workers' compensation claims . This accident form is not intended to take the place of workers' compensation claim forms.

Please be aware this form will time out after ten minutes of inactivity.

Are you submitting this for yourself or someone else? Required

myself

someone else

Name (First, M.I., Last) Required

Phone number Required

Email Required

Address Required

Campus affiliation

university employee (full-time, part-time, student employee)

student

campus visitor

Date of accident/injury Required

Approximate time of incident Required

Location of incident Required

Please provide the building and room number (eg: FAMA C109) If outside, please describe the closest location or landmark (e.g. parking lot x, intersection of x and y, stairs outside building x).

Describe the accident and events leading up to the accident.

In as much detail as possible, please describe the events leading up to the accident, describe the accident as it occurred, and describe the steps taken immediately after the accident. Describe any injuries and where on the body they occurred. Include any objects or substances involved.

Please describe the accident or injury and the events leading up to it. Required

Did you seek medical attention?

yes

Was there damage to university property or equipment?

yes

Were there any other people who saw the incident occur?

yes

Please attach any supporting documents (ex: pictures).

Files may not exceed 7MB

By submitting this form, you are agreeing that the information provided is true, correct, and complete to the best of your knowledge. Furthermore, you understand that any information provided on the accident/injury form will be used as part of an investigation by the University of Arkansas. Information shared here is not protected by the Health Insurance Portability and Accountability Act (HIPAA). Do not share overly sensitive personal or medical information or images.

ENHS | Accident Reporting Form

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Describe the accident and events leading up to the accident.