Personal Information

  • Phone Number

  • Street

  • City

  • State

  • Zip

  • Department

  • Other:

  • Position

  • Start Time

  • # of days since last day off

Incident Details

  • What type of incident are you reporting?

  • When did the incident occur?

  • When did you report the incident?

  • Who did you report the incident to?

  • Where did the incident occur

  • Other

  • If at a customer's location or on the road, what is the address? If no, mark NA.

  • Are there any witnesses?

  • If yes, please provide a name and contact number. If no, mark NA.

Injury Information

  • Is the injury directly related to work activities at Sysco Louisville, Inc.?

  • Describe how you became injured. Please be specific.

  • How could you have prevented this injury?

  • Part of body injured.

  • Right or left side?

  • Please describe the pain you are experiencing.

  • On a scale of 1-10 (10= intense pain, 1= little to no pain) how severe is your pain?

Treatment Options

  • Do you wish to seek medical treatment?

  • If yes, we follow our Corporate protocol and contact PC365, a registered nurse line, for medical assessment. Sysco Louisville, Inc. follows any and all recommendations from PC365. Your supervisor will initiate the phone call and transfer it to you. Phone # (866) 450-4110.

  • If no, please sign to refuse any and all medical treatment and/or transport to a qualified medial facility at this time. It is understood that these services are being offered to you by Sysco Louisville, Inc. This refusal is being voluntarily given with full knowledge of the possible consequences of the injury. If you selected yes, mark NA and sign.

  • If reporting this injury late, have you already received medical treatment?

  • If yes, where? If no, mark NA


  • Add pictures of the injury, if applicable.

  • Add drawing

Employee Signature: By signing below, you certify that the information provided in this report is a true and correct statement of the facts and that you made such statement of you own free will.

  • Employee

Supervisor Signature: By signing below, you verify that you have reviewed the incident with the employee.

  • Supervisor

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