Report an Injury, Safety Concern or Near-Missed

1. Select the information that best describes the incident:

    Injury/illness or possible injury/illness resulted from incident.
    Possible dangerous event, unsafe condition or unsafe behavior.

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