Personal Information

  • Employee Name

  • SSN#

  • Date of Birth

  • Date of Hire

  • 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 day the incident occur?

  • When did you report the incident (date/time)?

  • 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

  • Describe how you became injured. Please be specific.

  • How could this injury have been prevented?

  • Part of body injured.

  • Right or left side?

  • Is the injury directly related to work activities at Sysco St.Louis?

  • Please describe the pain you are experiencing.

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

  • Take a photo(s) of the injury if reasonable.

  • Take a photo(s) of the injury if reasonable.

Treatment Options

  • Do you wish to seek medical treatment?

  • 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.

  • Employee Signature

  • 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.

  • Employee Signature

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

  • If yes, where? If no, mark NA

Media

  • Add pictures of the injury, if applicable.

  • 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.

  • Employee

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

  • Supervisor

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