Employee Injury Report

• Name

• Sysco Association

  Employee

  Temp

  Leased Driver

  Visitor

• Current Date & Time

  Date

Personal Information

• Phone Number

• Street

• City

• State

• Zip

• Department

  Select Night Warehouse Day Warehouse Transportation Maintenance Fleet Other

  • Night Warehouse
  • Day Warehouse
  • Transportation
  • Maintenance
  • Fleet
  • Other

• Other:

• Position

• Start Time

  Date

• # of days since last day off

Incident Details

• What type of incident are you reporting?

  Employee Injury

  Non-Employee Injury

• When did the incident occur?

  Date

• When did you report the incident?

  Date

• Who did you report the incident to?

• Where did the incident occur

  Select Customer Location During On Road Collision Sysco Lot Sysco Dock Sysco Freezer Sysco Cooler Sysco Dry Other

  • Customer Location
  • During On Road Collision
  • Sysco Lot
  • Sysco Dock
  • Sysco Freezer
  • Sysco Cooler
  • Sysco Dry
  • Other

• Other

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

• Are there any witnesses?

  Yes

  No

• 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.?

  Yes

  No

  Unsure

• Describe how you became injured. Please be specific.

• How could you have prevented this injury?

• Part of body injured.

• Right or left side?

  Right

  Left

  NA

• 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?

  Select 1 2 3 4 5 6 7 8 9 10 no pain

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • no pain

Treatment Options

• Do you wish to seek medical treatment?

  Yes

  No

• 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.

  Sign

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

  Yes

  No

• If yes, where? If no, mark NA

Media

• Add pictures of the injury, if applicable.

  Media

• Add drawing

  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

  Sign

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

• Supervisor

  Sign