Injury or Illness Report


INSTRUCTIONS: This report should be submitted by individuals who have injuries on the UA campus. Also, employees who have an injury or illness that may be covered under the UA On-the-Job Injury and Illness Policy should complete this form.

Report Injury or Incident

Please choose one of the <br> following:

I am (choose one):
Treated in the ER?
Hospitalized overnight <br>as in-patient?
Primary <br>Treatment:
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