Date:

Type of Hazard (check appropriate radio button):
 Fire
 Health
 Mechanical
 Electrical
 Radiation
 Chemical/Biological
 Other

Building: 205 S. Cedar318 S. Pine601 S. CedarAdministration BuildingAHEC - DeltaAHEC - Fort SmithAHEC - North CentralAHEC - NortheastAHEC - NorthwestAHEC - Pine BluffAHEC - SouthAHEC - SouthwestArkansas Children`s HospitalBaptist Student Union BuildingBarton Research BuildingBiohazard Area (on F level of Parking Deck)Biomedical Research Building 1Biomedical Research Building 2BioVentures BuildingBlanford BuildingBoiler HouseBookstoreCancer Institute (ACRC)College of Public Health BuildingCommunity Womens Health ClinicDistribution CenterEducation Building WestEducation South (KARN Bldg)Educational Building IIEducational Building IIIFamily Medical CenterFreeway Medical CenterGroundsHead Start CentersInformation Technology (Computer Building)Institute on AgingJack Stephens Neurosciences BuildingJones Eye InstituteKids FirstMagnetic Resonance Imaging/Gamma KnifeMediplex ApartmentsOtherOutpatient Center 1Outpatient Center 2Outpatient Center Administration (5th and Cedar)Outpatient Diagnostic CenterPaint Shop / Flammable Storage BuildingParking Deck - EastParking Deck - NorthParking Deck - SouthPET BuildingPhysical PlantPsychiatric Research Institute BuildingRadiation Oncology Building (CARTI)Residence Hall Admin BuildingResidence Hall NorthResidence Hall SouthShorey BuildingSturgis Building (at ACH)Substance Abuse Treatment ClinicTrailer #1 - Elm StreetTrailer #2 - behind Family Medical CenterTrailer #3 - behind Family Medical CenterTrailer #4 - MRI Parking LotTrailer #5 - East of Outpatient Parking DeckUniversity HospitalUniversity TowerVA HospitalWard Clinical TowerWest Central Energy PlantWestmark BuildingWestside Building (at ACH)

Floor:

Room:

Location and Description of Hazard (Date, Time, Summary):
(limit 800 characters)

Your recommendation for correction (not mandatory):
(limit 400 characters)

Department:

First Name:

Last Name:

Work Phone:

Email Address:

UAMS ID Badge Barcode Number or SAP ID Number:

This is the number beneath the barcode on your UAMS Student or Employee ID Badge.
Your SAP ID number is found in the upper right hand corner of your UAMS ID.
Your First Name and Last Name must match the name listed for you in SAP.

By submitting this form, you are certifying that you are the individual named above.