DIN6 - DSP+First+Report+of+Safety+Incident+Form+rev1

DSP First Report of Safety Incident

Section 1: Station and Personnel Information
Who is filling out this form?

First NameLast Name
What type of incident was this?

Delivery Station
i.e. DIN6
DSP Name
i.e. Ripple Distribution LLC
DSP Login
i.e. RIPP
DA Name
i.e. Jon Doe
Transporter Identification
Found in Cortex>Admin>Associates
DA Time in Role ( Months )
Found in Cortex>Admin>Associates

Section 2: Injury/Illness Information

Complete this section for all incidents or injuries
Body Part Affected
Body Part Area
What specific job function was the DA performing when they were injured?
i.e. Walking to the front door
Incident Description: Describe the how, what, when, where, and injury/illness details of the incident
i.e. On 8.15.25 at 6:33pm, CX123 was walking to the front door of 12345 North Main Street Fort Wayne IN 46800 (TBA234567890123) when a dog ran and bit the DA's right leg. DA called the Police (report # 25F123456z) and LMET #EMT12345. DA treated the wounds himself and continued route.
Did the incident result in any of the following: Fatality, fracture (including fingers, toes, nose, and teeth; including hairline/stress fractures), degloving, amputation (including fingertip) and/or loss of an organ, loss of consciousness, concussion, or admittance to a hospital for (24) hours or more.
Did anyone observe the incident?
If yes whom
i.e. customer
Did the DA seek medical care?
Was the DA transported to the hospital via ambulance?
Were the DA's injuries life-threatening?
Were the DA's injuries pet/animal related?
Did the DA notice signs of a dog?
Did the DA create awareness (tap horn, rattle keys or gate) to alert a dog of their presence?
Did the DA see the pet/animal and still proceed?
Was the customer present during the incident?
Was there a Paw Print on the Rabbit device already for this address?

Section 3: Vehicle information

Use this section to document vehicle details, if a vehicle was involved in the incident event.
Vehicle Manufacturer?
Found in Cortex>Admin>Fleet>Search for Van
Vehicle Model?
Found in Cortex>Admin>Fleet>Search for Van
Vehicle Type?
Vehicle VIN
Found in Cortex>Admin>Fleet>Search for Van
Vehicle License Plate
Found in Cortex>Admin>Fleet>Search for Van
Vehicle License Plate State
Found in Cortex>Admin>Fleet>Search for Van
Is Netradyne installed in Vehicle?
Is the Vehicle Branded?
i.e. Amazon Logo on the side
Was the DA tested for drugs and alcohol?

Section 4: Incident/Event Information General Information- Complete if incident involved a vehicle
Date of IncidentEvent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of IncidentEvent

Hour Minutes

AM/PM Option
Shift Start Time?

i.e. 10:00am Minutes Minutes

AM/PM Option
Date of Report to DSP

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Report to Amazon

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was the Incident/Event Self-Reported?
Did the incident/event result in a police report?
If yes add police report #
Incident Description: Describe the how, what, when, where, and any other details of the incident
On 8.15.25 at 6:33pm, CX123 was driving to 12345 North Main Street Fort Wayne IN 46801 (TBA234567890123) when a community member ran into the side of the van. DA called the Police (report # 25F123456z) and LMET #EMT12345. DA continued route.
Did the vehicle rollaway?
Was vehicle put into park?
Was emergency brake engaged?
Was van off?
Is the telematics and/or netradyne available to review?
Did the event result in a fire and/or explosion?
Was there a HAZMAT spill?
Was vehicle (as applicable) hazard lights, turn signals, headlights, back up proximity alarm, and back up camera functioning?
Was there property damage other than the vehicle?
If yes, please describe:
Were any vehicles towed?
Were emergency medical services (EMS) or police called?
Was the driver found to be at fault by local authorities?
Were LMET/SDS and Amazon delivery station leadership immediately contacted?
Does the vehicle meet Amazon's roadworthy standards?
Does the vehicle requirement repair/maintenance prior to being release to service?

Who needs a copy of this report? Jaimee's email should already be filled. here
Enter jaimeediller@icloud.com
Should be Empty:

Section 2: Injury/Illness Information