DHL Supply Chain Incident Report

• Report Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Name

• Incident Type

  Accident

  Near-miss

• Date and time incident was reported.

  Date

• Date and time of incident

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Client informed?

  Yes

  No

  N/A

• Applicable "Safety First" Rules:

  Select Accident Reporting Loading Dock Manual Handling No Substance Misuse Pedestrian Walkway PPE Prevent Cuts Prevent Fires Racking Slips & Slips Vehicles, machinery, Equipment Work At Height

  • Accident Reporting
  • Loading Dock
  • Manual Handling
  • No Substance Misuse
  • Pedestrian Walkway
  • PPE
  • Prevent Cuts
  • Prevent Fires
  • Racking
  • Slips & Slips
  • Vehicles, machinery, Equipment
  • Work At Height

DETAILS OF INJURY, IF APPLICABLE

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  Select None Minor Serious Major

  • None
  • Minor
  • Serious
  • Major

• Photo of damage.

  Media

• Property Damage:

  Select Vehicle Equipment Private Property Other Damages N/A

  • Vehicle
  • Equipment
  • Private Property
  • Other Damages
  • N/A

• Photo of damage.

  Media

• Vehicle No:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Sign-off Date/ Time

  Date

• Signature

  Sign