Accident / Incident / Unsafe Condition Report

In the event of immediate danger, call University Police at (479) 575-2222 or visit safety.uark.edu for emergency information and procedures.

PLEASE NOTE: Any event involving workplace injuries must be reported directly to Risk Management using the appropriate University form to be considered for workers' compensation claims. This accident form is not intended to take the place of workers' compensation claim forms.

Please select one.

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1. REPORTER INFORMATION

Please enter your name.

Role of person reporting the event

PERMANENT RESIDENCE INFORMATION:

CAMPUS RESIDENCE / WORK INFORMATION: (if applicable)

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2. EVENT OR UNSAFE CONDITION DETAILS

Date event occurred

Where did the event occur? (e.g., building and room #)

Please describe what happened.

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3. INJURIES (if applicable)

Select one.

Please provide the name of the injured party.

Select one.

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4. PROPERTY DAMAGE (if applicable)

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5. WITNESSES (if applicable)

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6. REPORTING

Did you report the event to someone (other than by this form)?

Phone # of the person to whom you reported this event.

 

I certify that all of the above is true and correct to the best of my knowledge.

If you have any questions regarding your submission, please call (479) 575-6601 or direct e-mail to fama@uark.edu.