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Employee Incident/Accident Report Form
Employee Incident/Accident Report Form
Fill Out for DA. If an emergency, call 911 first. For other injuries, call the Nurse Triage Hotline at (855) 777-7090. Company name: Winterwood Business Solutions. Address: 19 North Main Street, Petersham MA 01366. Worker's Compensation Policy Number: WCC360259A. Then call Amazon Last-Mile Emergency Team: (844) 311-0406 Extension 3, 1, 4. Company Name: The Parcel Team. Address: same as above.
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    Drag and drop files here
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    Max. file size: 10.6MB
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    Please Select
    • Please Select
    • Customer’s Driveway
    • Customer’s Premises
    • Customer’s Yard
    • Company Office
    • Offsite Lot
    • Road
    • Inside Van
    • Warehouse
    • Other
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    Please Select
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    • Ice, sleet, snow, freezing
    • Rain
    • Restricted space
    • Rubbish, debris, general untidiness
    • Sunny and fair
    • Dark
    • Tidy, well lit, no obstructions
    • Other
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    Please Select
    • Please Select
    • Delivering
    • Driving
    • Loading
    • Office Work
    • Packing
    • Picking
    • Put away
    • Unloading
    • Other
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    Please Select
    • Please Select
    • Bending
    • Entering Van
    • Exiting Van
    • Lifting
    • Pushing
    • Repetitive movement
    • Stair stepping
    • Turning
    • Twisting
    • Walking
    • Running
    • Other
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    • 0 No Pain
    • 1 Mild
    • 2 Moderate
    • 3 Severe
    • 4 ICU
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    If yes, upon Supervisor approval, please call (516) 660-8562, #2, #2 to speak to our Company Doctor.
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    Supervisor call (855) 777-7090 to report a personal infury to the Nurse Triage Hotline and call AMZL Last-Mile Emergency Team at (844) 311-0406 Extension 3, 1, 4 to report incident to Amazon.
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    Supervisor, you can sign this online or print out the report and sign it manually.
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    Supervisor, print out the report and have the Employee sign it manually at the end of the shift.
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    I, ___________________________________________ (name) have been offered the opportunity to have medical care for the above-mentioned injury by my employer. I feel that I do not require medical care at this time and can return to work.
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