* Required Information

Part 1 — Employee Information

Date of Birth
Home Address*
xxx xxx xxxx
Preferred: UB email address
Work Status*
Usual Work Days
For example: 9am-5pm
Building, Room
State Bargaining Unit

Part 2 — Incident Details

Date of Incident*
Time of Incident*
Date Supervisor Notified*
Time Supervisor Notified*
Time Lost?*
8 digits
Examples: Building & Room, Parking Lot #
Nature of the Incident*
Select One
Body Part(s) Affected*
Check All That Apply
Examples: concrete floor, chlorine, radial arm saw
Side of the Body
Number of Witnesses
Separate Names with Commas
Be Specific
Be Specific
Medical Treatment Provided By
Check All That Apply
Treatment Date