Last Revised: June 07, 2023

All injuries must be reported immediately. Supervisors or Managers must complete this incident report and submit it to EHRS within two business days. 

Please note, this is the form for ULAR.  If you are looking for the (unrelated) Accident/Incident report for FRES, go here.

Information on Employee Who Had Incident
Nature of Accident or Incident
(ex. burn to left hand, fracture to left ankle)
Witness Name
more items
Did employee receive a medical evaluation?
Does this injury have the potential to result in an inpatient hospitalization, amputation, or loss of an eye?
Preventive Actions
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