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.

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.

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: _____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.

If yes, was the injury reported to Amazon: Yes No

Initial Pain Level (1 – Least Severe to 10 – Most Severe): ____ Pain Level – Post-First Aid Care (1 – Least Severe to 10 – Most Severe): ____

Was the DA transported to the hospital via ambulance? Yes No

Was the injury related to a package, or was the DA holding a package when injured? _____Yes or _____No If yes, please answer following questions:

· Provide the Package TBA number: _______________

· Describe the action being performed: ___________________________________________________________________________________________

· Did this incident take place at the launchpad/station, inside the van, walking to the delivery location, returning form the delivery location, or somewhere else (provide location)?

____________________________________________________________________________________________________

· Were stairs involved? _____Yes or _____No

Section 3: Vehicle information

Use this section to document vehicle details if a vehicle was involved in the incident event.

Fill out the information below for the date of incident/event and the (4) week trailing number. (Date of incident / (4) week trailing)

Section 4: Incident/Event Information

Vehicle Event Information

Use this section to document all event details. Use the diagram on page 4 to illustrate the incident/event.

Diagram of Acc

ident Scene:

Consider the following whe

n illustrating the inciden

t/event in the diagram bel

ow:

• What was th

  e direction

  of travel?

• Was anyone making a turn and what o

  peration were all parties involved

  in completing at the time of incide

  nt?

• Was it a stop s

  ign or stop lig

  ht intersection

  ?

Section 5: Incident/Event Investigation, Root Cause and Corrective/Preventative Action (CPA)

Use this section to document the incident/event investigation and CPA results. Partner with local Amazon delivery station leadership and/or workplace health and safety (WHS) as needed.

CPA Best Management Practices

CPAs should:

• Align with problem/need/gap (i.e. immediate and root causes)
• Be proportionate to the hazard/risk identified
• Provide immediate and long-term risk mitigation
• Be actionable, enforceable, measurable, and sustainable
• Be assessed post-implementation to determine efficacy
• State an estimated completion date (ECD) and action owner

^{Amazon Leadership Only: Use all the information and inputs in this report to articulate and document a cohesive incident/event description in Austin/Gensuite. If the vehicle was branded and/or a step van, pull telematics information (e.g. seat belt status) and add to incident description. If vehicle and/or incident/event footage is available, add it to the report in Austin/Gensuite. If a site stand -down and/or network stand-down was necessitated, please note when the stand down(s) was completed. Contact local or regional WHS for additional support.}