Autonomous Delivery Robot Safety Incident Report Form
Please use this form to report any safety incidents involving autonomous delivery robots. Your report helps us improve safety and service quality.
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Robot Identification Number or Description
Type of Incident
*
Please Select
Collision with object or vehicle
Collision with person
Robot malfunction or breakdown
Near miss (no contact)
Obstacle detected and avoided
Other
Brief Description of the Incident
*
Were there any injuries?
*
No injuries
Minor injuries (no medical attention required)
Medical attention required
Were emergency services contacted?
*
Yes
No
Upload Photo or Document (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Your Name (optional)
Your Email Address
*
example@example.com
Submit Incident Report
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