DSP First Report of Safety Incident - PDF Templates

DSP First Report of Safety Incident

Purpose: To facilitate the motor vehicle accident (MVA) incident and event reporting process, in addition to ensuring conformant/compliant incident/event investigation(s), and subsequent actions and communications.

Scope: All AMZL/AMXL Operations and Delivery Service Partners (DSPs) in North America (NA).

Instructions for Use: DSPs shall use this packet to document the incident/event report from the Delivery Associate (DA) involved in the incident. DSPs shall also use this form to initiate and facilitate the incident/event investigation process, to identify immediate and root cause(s) of the incident/event. DSPs shall encourage DAs to immediately report all incidents and events to their DSP. DSPs are required to attain the report, document it (using this packet), and submit it (in addition to the completed DA Incident Packet) to their local Amazon Operations leader within (24) hours of the incident/event being reported and/or identified. Amazon Operations shall enter the incident/event into Austin/Gensuite by the end of the shift the incident/event was reported to them.

There are 3 types of incidents/injuries that require completion of different sections.

Motor vehicle event without injuries which requires sections 1, 3, 4, and 5 to be completed
Motor vehicle event with injuries which requires all 5 sections to be completed
Injury not involving motor vehicle which requires sections 1,2, and 5 to be completes

Important For Amazon Leaders: If an incident resulted in a 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, ensure the incident is escalated to the delivery station’s Regional Workplace Health and Safety Manager within (1) hour of the incident being reported and/or identified.

Section 1: Station and Personnel Information

Complete this section for all incidents or injuries

Delivery Station ID (e.g. DLA1): __________

DSP Name: _______________ DSP Login: ______________ DA Name: __________________ DA Login:__________________

Transporter Identification: __________________ DA Time in Role (Months): _____ Date of Initial Training: ______________

Is the DAs training up to date? Yes No If no, provide details as to what/why: ___________________________________________________________________________________________

Section 2: Injury/illness Information

If there was an incident (injury/illness) complete this section below. If a MVA occurred and it Did Not result in an incident, mark as None Applicable (NA) and move forward to the vehicle information section 3.

Body Part Affected: ___________________ Body Part Area: ___Left ___Right ___Both

What specific job function was the DA performing when they were injured (e.g. walking to the front door)? __________________________________________________________________________________________________

Incident Description (Describe the how, what, when, where, and injury/illness details of the incident) ________________________________________________________________________________________________________________________________________________________________________________________________________

Did the incident result in any of the following (check all that apply):

□ Fatality □ Fracture (including fingers, toes, nose, and teeth; including hairline/stress fractures)

□ Degloving (large piece of skin, muscle or tissue missing) □ Amputation (including fingertip)

□ Loss of an organ □ Loss of consciousness □ Concussion □ Admittance to a hospital for (24) hours or more

□ Other