Accident/Incident Report - ULAR

Supervisor's Full Name

Your Email

Information on Employee Who Had Incident

Employee First Name

Employee Last Name

Job Title

Employee Penn ID

Nature of Accident or Incident

Incident Date

Approximate Incident Time

Date Reported

Building Name

Room Number

Summary/Location of Injury

(ex. burn to left hand, fracture to left ankle)

Witness(es)

Witness Name
Witness Name

more items

Did employee receive a medical evaluation?

Yes

Date of Medical Evaluation

Location of Medical Evaluation

Description of Accident or Incident

Does this injury have the potential to result in an inpatient hospitalization, amputation, or loss of an eye?

Yes

List PPE In Use

Preventive Actions

Recommended Preventive Action(s)

Certification

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