BMS Accident Incident Report Form

For ALL emergencies, contact Campus Police-
9-911 from a campus phone or 229-9911 from a cell phone.

If this incident involves any type of personal injury or property damage, additional campus reports must also be completed. Please see the Accident, Incident, and Injury Reporting page for instructions on proper incident reporting. If you are unsure if you need additional report forms, contact your instructor, supervisor, PI, or click here to Contact Us.

BMS Accident/Incident Report Form

Report is sent to the Laboratory Manager, and will be forwarded to the appropriate Department of Biomedical Sciences program director and placed in the student file (if applicable).

Name*
First Last
Phone*
Email*

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Date of Incident*
MM slash DD slash YYYY
Approximate Time of Incident

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What is your role at UWM?*
If you fit multiple roles, chose the one in which you were working when the incident occurred.
Did this incident happen during or while preparing for a class?*
Instructor of course*
Other*
Course #*
Other*

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Description of injury/incident:*
Does this incident involve an exposure to blood, body fluids, or other potentially infectious material?*
Source of Exposure (ex. blood, urine, CSF, etc.)*
Please include identification of source, if available (name, number, email, etc.)
Could this incident have been prevented?*
Please describe how this could have been prevented.*
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Were any safety rules violated?*
Please describe which safety rules were violated.*
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Please list any pertinent witnesses below, including contact information
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Was any treatment rendered?*
What treatment?*
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Was person referred to a clinic or hospital?*
Which clinic or hospital?*
Other*

University of Wisconsin-Milwaukee

College of Health Professions & SciencesBiomedical Sciences Labs

BMS Accident/Incident Report Form