Incident Report   EMPLOYEE VISITOR VOLUNTEER STUDENT	Today’s Date ___________________ Incident Date ___________________ Incident Time _____________ am | pm
Before completing report, read instructions. Form must be completed by Supervisor.

[] University Hospital [] SOM [] NJDS [] RWJ [] NJMS [] SHRP [] GSBS [] UBHC / NWK [] UBHC - Piscataway [] School of Nursing [] Central Administration [] CINJ [] Eric Chandler []Other

___________________________________________________ _____________ _____________ _____________ Subject of Incident(last name, first name, middle initial) Date of Hire Date of Birth Sex ________________________________________________________________ ____________________________ Permanent Address Home Phone Type of Incident: [] Slip & Fall [] Theft [] Unlocked Door ____________________________ Other___________________________________ Exact Location of Incident Type of Injury____________________________________________________________________________________ Body Part Affected/Impacted_________________________________________________________________________

Subject (check one) [] Employee (If checked, completed form must be forwarded by subject and/or supervisor)	____________________________ ______________________ ______________________ Department Social Security No. Job Title 1. Was employee on duty? [] Yes [] No 6. If Yes to item 4, work 2. Did employee require medical attention? [] Yes [] No was ceased ______ am | pm 3. Was employee in his assigned area? [] Yes [] No 7. If Yes to item 4, date work 4. Did employee cease work due to incident? [] Yes [] No was ceased ______ am | pm 5. Do you agree with employee’s verbal account of incident? [] Yes [] No
[] Visitor [] Volunteer [] Student [] Other	Occupation/Employer_________________________________________________________________ _________________________________________ ____________________________ Reason for presence at the UMDNJ Health Insurance Center
Incident Facts	Description of incident (state all facts clearly using subject’s own words)       [] Needle Stick Incident [] Device/Brand Type__________________________ Body Part:_____________________________________________________ Was Needle Stick EOHSS report done? [] Yes [] No Witnesses: 1. Name:________________________________ Home Phone:_____________________ 2. Name:________________________________ Home Phone:_____________________
[] Property Damage [] Missing Article	Owner of Property ________________________________________________________ Notified Public Safety [] No _______________________________   [] Yes - Time _________ Nature and Extent of loss     Article insured [] Yes [] No- Carrier______________
Nature of Injury (If Applicable)	Was person involved examined by a physician in hospital? [] Yes [] No Date:_________ Subject complained of injury? [] Yes [] No Examination and treatment refused? [] Yes [] No Physician's Name(print)______________________________________________
Signature	____________________________________________ _________________ _________________ Signature and title of person preparing report Dept. Phone ext.
UMDNJ-Form 70    Distribution: White - Risk & Claims   Pink- Preparer    Canary-E.O.H.S.S Public Safety Dept