Customer Accident/Incident Report Form

1
Customer Name* This field is required.
First Name
Last Name
2
Customer Phone Number* This field is required.
Area Code
Phone Number
3
Customer Email* This field is required.
example@example.com
4
Date of incident/Accident* This field is required.
Date
Month
Day
Year
5
Time of incident/Accident* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
6
Location* This field is required.
7
Location description* This field is required.
Please Select
Please Select
Customer’s Driveway
Customer’s House
Customer’s Yard
Office area
Road
Van
Warehouse
Other
8
Area conditions* This field is required.
Please Select
Please Select
Ice, sleet, snow, freezing
Rain
Restricted space
Rubbish, debris, general untidiness
Sunny and fair
Tidy, well lit, no obstructions
Other
9
Which task was Driver performing at the time of the incident/Accident?* This field is required.
Please Select
Please Select
Delivering
Driving
Loading
Office Work
Packing
Picking
Put away
Unloading
10
Description of Incident/Accident* This field is required.
11
Download Picture(s) Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Were there any witnesses?* This field is required.
YESNO
13
First witness name
14
First witness phone number
Area Code
Phone Number
15
Second witness name
16
Second witness phone number
Area Code
Phone Number
17
Amazon Driver's vehicle license plate
18
Customer's vehicle license plate
19
Customer's license number
20
Were the police called?* This field is required.
YESNO
21
Police officer name and ID
22
Was the Customer injured?* This field is required.
YESNO
23
Customer injury: 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
24
How would you, the Customer, rate your level of pain?* This field is required.
0 None
1
2
3
4 Most severe
25
Describe your injury, if any
26
Was an ambulance called?* This field is required.
YESNO
27
Ambulance ID
28
Did you, the Customer, seek medical attention?* This field is required.
YESNO
29
Medical facility used
30
Was the Customer's vehicle or property damaged?* This field is required.
YESNO
31
Description of damage to Customer's vehicle or property
32
Customer Other Explanation/Notes
33
Name of Person Filing Report* This field is required.
First Name
Last Name
34
Phone of Person Filing Report* This field is required.
Area Code
Phone Number
35
Email of Person Filing Report* This field is required.
example@example.com
Should be Empty: