Title Page
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Name
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Take a clear photo of the employee
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Sysco Association
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Current Date & Time
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Prepared by
Personal Information
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Employee Name
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SSN#
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Date of Birth
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Date of Hire
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Phone Number
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Street
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City
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State
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Zip
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Department
- Night Warehouse
- Day Warehouse
- Transportation
- Maintenance
- Fleet
- Other
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Other:
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Position
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Start Time
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# of days since last day off
Incident Details
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What type of incident are you reporting?
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When day the incident occur?
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When did you report the incident (date/time)?
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Who did you report the incident to?
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Where did the incident occur
- Customer Location
- During On Road Collision
- Sysco Lot
- Sysco Dock
- Sysco Freezer
- Sysco Cooler
- Sysco Dry
- Other
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Other
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If at a customer's location or on the road, what is the address? If no, mark NA.
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Are there any witnesses?
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If yes, please provide a name and contact number. If no, mark NA.
Injury Information
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Describe how you became injured. Please be specific.
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How could this injury have been prevented?
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Part of body injured.
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Right or left side?
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Is the injury directly related to work activities at Sysco St.Louis?
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Please describe the pain you are experiencing.
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On a scale of 1-10 (10= intense pain, like cutting off your arm; 1= little to no pain) how severe is your pain?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- no pain
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Take a photo(s) of the injury if reasonable.
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Take a photo(s) of the injury if reasonable.
Treatment Options
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Do you wish to seek medical treatment?
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If "No", we follow our Corporate protocol and contact PC365, a registered nurse line, for medical assessment. Sysco St. Louis follows any and all recommendations from PC365. Your supervisor will initiate the phone call and transfer it to you. Phone # (866) 450-4110. Also, please sign below acknowledging that you may change your mind at any time and seek medical care by notifying your supervisor.
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Employee Signature
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If "Yes", we follow our Corporate protocol and contact PC365, a registered nurse line, for medical assessment. Sysco St. Louis follows any and all recommendations from PC365. Your supervisor will initiate the phone call and transfer it to you. Phone # (866) 450-4110.
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Employee Signature
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If reporting this injury late, have you already received medical treatment?
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If yes, where? If no, mark NA
Media
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Add pictures of the injury, if applicable.
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Describe the injury
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.
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Employee
Supervisor Signature: By signing below, you verify that you have reviewed the incident with the employee.
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Supervisor
