Instructions: Please complete the following and click CONTINUE to report an incident.
If more than one person was injured, please submit a report for each
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?
3. Was a vehicle involved?
4. If a vehicle was involved,
was it? (choose one):
Resources: Insurance & Risk
MEDICAL CENTER: Workers' Compensation : Environmental Health & Safety