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Employee Incident/Accident Report Form
Dispatcher: Fill Out for DA, Then Call AMZL Last-Mile Emergency Team at (844) 311-0406 Extension 3, 1, 4
51
Questions
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1
Employee Name
*
This field is required.
First Name
Last Name
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2
Employee Phone Number
*
This field is required.
Area Code
Phone Number
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3
Employee Email
*
This field is required.
example@example.com
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4
Date of incident/Accident
*
This field is required.
Date
Month
Day
Year
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5
Time of incident/Accident
*
This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
AM
AM
PM
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6
Route Number
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7
Stop Number
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8
TBA Number of Delivery Closest to Incident
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9
Location
*
This field is required.
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10
Location description
*
This field is required.
Customer’s Driveway
Customer’s House
Customer’s Yard
Office area
Road
Van
Warehouse
Other
Customer’s Driveway
Customer’s House
Customer’s Yard
Office area
Road
Van
Warehouse
Other
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11
Area conditions
*
This field is required.
Ice, sleet, snow, freezing
Rain
Restricted space
Rubbish, debris, general untidiness
Sunny and fair
Tidy, well lit, no obstructions
Other
Ice, sleet, snow, freezing
Rain
Restricted space
Rubbish, debris, general untidiness
Sunny and fair
Tidy, well lit, no obstructions
Other
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12
Which task was being performed at the time of the incident/Accident?
*
This field is required.
Delivering
Driving
Loading
Office Work
Packing
Picking
Put away
Unloading
Delivering
Driving
Loading
Office Work
Packing
Picking
Put away
Unloading
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13
Which type movement was being used at the time?
*
This field is required.
Bending
Entering Van
Exiting Van
Lifting
Repetitive movement
Stair stepping
Turning
Twisting
Walking
Bending
Entering Van
Exiting Van
Lifting
Repetitive movement
Stair stepping
Turning
Twisting
Walking
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14
Description of Incident/Accident
*
This field is required.
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15
Download Picture(s) Here
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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of
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16
Were there any witnesses?
*
This field is required.
YES
NO
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17
First witness name
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18
First witness phone number
Area Code
Phone Number
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19
Second witness name
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20
Second witness phone number
Area Code
Phone Number
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21
Employee's vehicle license plate
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22
Other party's vehicle license plate
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23
Other party's driver's license number
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24
Were the police called?
*
This field is required.
YES
NO
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25
Police officer name and ID
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26
Were you injured?
*
This field is required.
YES
NO
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27
DA injurey: body part(s)
Ankle, Left
Ankle, Right
Arm, Left
Arm, Right
Back
Bottom
Chest
Foot, Left
Foot, Right
Hand, Left
Hand, Right
Head
Groin
Knee, Left
Knee, Right
Neck
Shoulder, Left
Shoulder, Right
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28
How would you rate your level of pain?
*
This field is required.
0 None
1
2
3
4 Most severe
0 None
1
2
3
4 Most severe
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29
Did you continue working?
YES
NO
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30
Describe your injury, if any
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31
Was the other party injured?
*
This field is required.
YES
NO
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32
Other party's injury: body part
N/A
Ankle, Left
Ankle, Right
Arm, Left
Arm, Right
Back
Bottom
Chest
Foot, Left
Foot, Right
Hand, Left
Hand, Right
Head
Groin
Knee, Left
Knee, Right
Neck
Shoulder, Left
Shoulder, Right
N/A
Ankle, Left
Ankle, Right
Arm, Left
Arm, Right
Back
Bottom
Chest
Foot, Left
Foot, Right
Hand, Left
Hand, Right
Head
Groin
Knee, Left
Knee, Right
Neck
Shoulder, Left
Shoulder, Right
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33
Describe the other party's injury, if any
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34
Was an ambulance called?
*
This field is required.
YES
NO
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35
Ambulance ID
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36
Did either party seek medical attention?
*
This field is required.
YES
NO
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37
Medical facility used
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38
Was your vehicle or company property damaged?
*
This field is required.
YES
NO
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39
Description of damage to your vehicle or company property
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40
Was the other party's vehicle or property damaged?
*
This field is required.
YES
NO
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41
Description of damage to other party's vehicle or property
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42
Employee Explanation/Notes
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43
Is Employee's training up to date?
*
This field is required.
YES
NO
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44
Was the appropriate PPE worn?
*
This field is required.
YES
NO
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45
Describe the root cause of the incident
*
This field is required.
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46
What corrective actions can prevent re-occurrence?
*
This field is required.
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47
Employee Date of Hire
Date
Year
Month
Day
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48
Employee Last Date of Training
Date
Year
Month
Day
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49
Name of Person Filing Report
*
This field is required.
First Name
Last Name
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50
Phone of Person Filing Report
*
This field is required.
Area Code
Phone Number
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51
Email of Person Filing Report
*
This field is required.
example@example.com
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