Employee Accident/Incident Report Form

Date of incident/Accident* This field is required.

Date

Employee Name* This field is required.

First Name

Last Name

Employee Phone Number* This field is required.

Area Code

Phone Number

Employee date of birth* This field is required.

Date

Employee Email* This field is required.

example@example.com

Upload Photos of Scene of Incident, Damage, Other Party's Driver's License, Vehicle License, and Insurance Card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Employee FICO Score (Dispatcher Look at Mentor)* This field is required.

Time of Incident/Accident

Route Number* This field is required.

TBA Number of Delivery Closest to Incident

Location* This field is required.

Location description* This field is required.

Area conditions* This field is required.

Which task was being performed at the time of the incident/Accident?* This field is required.

Which type movement was being used at the time?* This field is required.

Employee's Description of Incident/Accident* This field is required.

Were there any witnesses?* This field is required.

YESNO

First witness name

First witness phone number

Area Code

Phone Number

Second witness name

Second witness phone number

Area Code

Phone Number

Were the police called?* This field is required.

YESNO

Police officer name and ID

Were you injured?* This field is required.

YESNO

DA Injury (if any): Body Part(s)

Shoulder, Left

Shoulder, Right

Arm, Left

Arm, Right

Wrist, Left

Wrist, Right

Hand, Left

Hand, Right

Leg, Left

Leg, Right

Knee, Left

Knee, Right

Ankle, Left

Ankle, Right

Foot, Left

Foot, Right

Head

Nose

Eye, Left

Eye, Right

Ear, Left

Ear, Right

Neck

Back

Bottom

Chest

Groin

Other

Describe your injury, if any

How would you rate your level of pain?* This field is required.

Did you continue working?* This field is required.

YESNO

Did you wish to seek medical attention?* This field is required.If yes, upon Supervisor approval, please call (516) 660-8562, #2, #2 to speak to our Company Doctor.

YESNO

Was the other party injured?* This field is required.

YESNO

Other Party Injury (if any): Body Part(s)

Shoulder, Left

Shoulder, Right

Arm, Left

Arm, Right

Wrist, Left

Wrist, Right

Hand, Left

Hand, Right

Leg, Left

Leg, Right

Knee, Left

Knee, Right

Ankle, Left

Ankle, Right

Foot, Left

Foot, Right

Head

Nose

Eye, Left

Eye, Right

Ear, Left

Ear, Right

Neck

Back

Bottom

Chest

Groin

Other

Describe the other party's injury, if any

Was an ambulance called?* This field is required.

YESNO

Did the other party seek medical attention?* This field is required.

YESNO

Was your vehicle or company property damaged?* This field is required.

YESNO

Description of damage to your vehicle or company property

Was the other party's vehicle or property damaged?* This field is required.

YESNO

Description of damage to other party's vehicle or property

Employee Additional Explanation/Notes

Is Employee's training up to date?* This field is required.

YESNO

Describe the root cause of the incident* This field is required.

What corrective actions can prevent re-occurrence?* This field is required.

Supervisor Additional Explanation/Notes

Name of Supervisor Filing Report* This field is required.Supervisor call (516) 660-8562, #2, #1 to report incident to Acuity and call AMZL Last-Mile Emergency Team at (844) 311-0406 Extension 3, 1, 4 to report incident to Amazon.

First Name

Last Name

Phone of Supervisor Filing Report* This field is required.

Area Code

Phone Number

Email of Person Filing Report* This field is required.

example@example.com

Supervisor SignatureSupervisor, you can sign this online or print out the report and sign it manually.

Employee SignatureSupervisor, print out the report and have the Employee sign it manually at the end of the shift.

Clear

Employee Signature if Declining Medical CareI, ___________________________________________ (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.

ClearSupervisor, have Employee Sign and Date