UAMS ADMINISTRATIVE GUIDE
REVISION: 10/11/04, 9/1/2007
|AREA:||GENERAL AND OCCUPATIONAL SAFETY|
The purpose of this policy is to establish procedures for reporting all accidents/injuries in a timely manner and to ensure that the required forms are completed and processed.
All UAMS employees, faculty and staff.
(1) All accidents resulting in injury to employees and students must be reported on the Employee/Student/Visitor Injury and Incident Report Form (Stockroom #51100). In the case of an employee, the report is to be completed by his or her supervisor or in the case of a student, by the attending physician.
(2) Contract employee injuries must be reported on the Variance Report Form (Stockroom #51165). These forms are to be completed by nursing personnel and forwarded to Occupational Health and Safety.
(3) When an employee has an “on the job injury”, Worker’s Compensation forms must also be completed.1
(4) All patient and visitor-related accidents/incidents must be reported on Variance Report Form on the web-based Patient Safety Net, wich is an electronic reporting system.
Employee/Student Injury Incident Report Form available by downloading this pdf file:
Patient / Visitor Variance Reporting Form:
1 UAMS Policy 4.1.08
SIGNATURE: ________________________________ DATE: _________________________
EMPLOYEE/STUDENT INJURY AND INCIDENT REPORT INSTRUCTIONS
All accidents on UAMS property that result in injury to employees and students must be reported on this form. Employees who receive injury must complete the form with their supervisors and obtain their signatures. Students should complete Section A (and Section C if applicable) with their attending physician.
COMPLETING THE FORM
(1) Name: Enter the name of the injured person.
(2) SSN#: Enter the Social Security Number of the injured person.
(2) DOB: Enter the injured person’s date of birth.
(3) Race/Sex: Enter the injured person’s race and sex in the corresponding spaces.
(4) Medical Record #: Enter the medical record number of the injured person.
(6) Address: Enter the current address of the injured person.
(7) Dept. or School: Enter the injured person’s department name or school.
(8) Job Title: Enter the injured person’s job title.
(9) Date/Time/Location of Accident/Injury: Enter the date, time and location (being as accurate as possible) where the accident and/injury occurred.
(10) Accident Type: Select the most appropriate category for the type of incident that caused the injury. Needle sticks are typically classified as “Struck By”. Blood/body fluid exposures are typically classified as “Contact with … substances”.
(11) Description of Accident/Injury/Exposure: Describe in detail the circumstances of the accident. Include where and how the accident occurred, and describe the extent of the injury. If the accident involved equipment of any kind, include a specific description of the equipment and how it was involved (e.g. type of equipment, type of needle, etc.).
(12) Name of Object or Substance which directly injured employee/student: List the name of the item or chemical which directly inflicted the injury.
(13) Yes/No/Unknown: If the injury involved the sticking of a needle or a sharp object, then check “Yes” and complete Section C (Instruction #15). If the answer is “No” or “Unknown,” simply check the appropriate space.
(14) If during the injury a mucous membrane was exposed to blood or body fluids, or skin was exposed to large amounts of blood or prolonged contact with blood, then complete Section C.
(15) Signature: The employee or student who has been injured must enter his or her signature in the Employee/Student column. Also in this column, enter the date and the injured person’s telephone extension number. In the Witness column, a signature from a witness of the accident, along with the date and the person’s telephone extension, may be entered. In the Supervisor/Instructor column, obtain the signature of the injured employer’s supervisor or the student’s instructor.
(16) Section B: This section will be completed by a Student/Employee Health Physician or ER Physician.
(17) Section C: This section will be completed if necessary by both the source patient and the attending physician.
a) Name: Enter the name of the injured person.
b) Physician: Enter the name of the physician who attended the injured person.
c) Unit #: Enter the unit number of the attending physician.
d) Physician’s Beeper #: Enter the beeper number of the attending physician in case emergency contact is required.
e) Date Drawn/Refused Testing: The attending physician will enter the date the lab work was done.
f) Nurse/Physician Signature: The nurse or attending physician will enter his/her signature here.
Variance Forms I and II available by downloading these pdf files: