Incident Report

Date / Time of the Incident:

Date

Time

DA Name *

First

Last

Van Number being driven by DA.

Email

Type of Form

Select Catagory: *

Accident
Incident (Dog bites, property damage, etc.)

Incident Involving

Astro Employee only
Astro Employee and Amazon Employee
Astro Employee and Customer

Incident Location

Warehouse (35 National dr)
Customer locatoin

Accident Sub Category

Major Accident Required Towing or Medical Attention
Minor Accident Repairs required
Report only - No damage or Injury

Incident Sub Category

Amazon Employee Name: *

First

Last

Customer Name *

First

Last

Customer Phone

Customer Email *

LMET Number:

Police Report Number:

Customer Insurance Policy Provider:

Customer Insurance Policy #:

Customer Vehicle Make/Model:

Customer Vehicle License Plate #:

Customer Vehicle Vin#:

What part of the Customer Vehicle was damaged?

Does the DA stated above require medical attention:

Yes
No

How bad was the injury?

Who went to the hospital?

Who was injured?

Where is the injury on the person?

Head and Neck

Upper Body (Torso)

Arms and Hands

Lower Body (Torso and Legs)

Legs and Feet

Other

TBA#

Address Of the Incident:

Address Line 1

Address Line 2

City

State

Zip Code

Statement of Problem:

Drivers are aware that both Astro Logistics Policy as well as Amazon Policy strictly REQUIRES them to follow all rules and regulation of safe driving put forth by DOT. Drivers should not have any Speeding, Seatbelt, Distraction, or other unsafe driving events while they are using the company vehicle.

Statement of Problem (attendance):

Astro Logistics Policy REQUIRES all Employees to report to work on their scheduled days. If drivers are unable to do so, they must call in 2 hours before the start of their shift and inform their supervisor.

Corrective Action:

The following actions have been explained in detail to the DA.

Failure to comply:

Failure to comply with the corrective action could lead to suspension or termination of assignment.

Employee Comment:

What happened? *

Please provide a detail description of what happened, who was involved, any damages, please be as detailed as possible. You can note the time, weather, location, etc.

Why did it happen? *

What caused the accident/incident? Please provide details as to what your role was in the accident.

What could you have done to prevent it? *

How this type of incident be prevented in the future? Be detailed in this answer, think of it as a learning tool for other drivers. What could you have done differently?

Additional Information:

Provide any additional information or comments to help better understand the situation.

Picture 1

Click or drag a file to this area to upload.

Please take a picture of any damages

Picture 2

Click or drag a file to this area to upload.

Please take a picture of any damges

Employee Signature

Supervisor Signature