Report an Injury, Safety Concern or Near-Missed

1. Select the information that best describes the nature of the incident:

    Injury/illness - resulted from an incident.
    Safety Concern - unsafe condition or unsafe behavior.
    Near Miss - event that could have resulted in an injury/illness or caused property damage.

2. What is the affiliation of the person for whom this form is being completed?

    UC Irvine CAMPUS Employee (including SOM employees working at UCIMC)
    UC Irvine MEDICAL CENTER Employee
    Student Employee
    UC Irvine Student Only (Not an employee)
    Other

3. Was a vehicle involved?   

   Yes   No