Transportation Accident: Employee Report

• Name

• Current Date & Time

  Date

Personal Information

• Phone Number

• Street

• City

• State

• Zip

• Driver License Number

• Position

• What time did you start your shift?

  Date

• # of days since last day off

Incident Details

• What type of accident are you reporting?

  Motor Vehicle Accident

  Property Damage

  Non-Employee Injury

• When did the incident occur?

  Date

• Who did you report the incident to?

• When did you report the incident?

  Date

• Describe the incident. Please be specific.

• How could the incident be prevented?

• Location incident occured

  Customer Location

  On the Road

  Sysco Lot

  Other

• Customer Name

• Street

• City

• State

• Zip

• Are there any witnesses?

  Yes

  No

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

• Did adverse conditions (road, traffic, weather) impact this incident?

  Yes

  No

• If yes, please describe. If no, mark NA.

• Were the police involved?

  Yes

  No

• If yes, what department? If no, mark NA

• Hazardous Material Spill?

  Yes

  No

  Unsure

• Were you cited for this incident?

  Yes

  No

  Not Applicable

• If yes, what for? If no, mark NA.

• Any vehicles towed?

  Yes

  No

  Not Applicable

• Tractor #

• Trailer #

• Route #

• Describe any damages

• Pictures taken and sent to supervisor?

  Yes

  No

• Was another person involved in the incident?

  Yes

  No

  Not Applicable

• If yes, please list name & contact number. If no, mark NA.

Media

• Pictures

  Media

• Sketch the incident

  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