Sample Accident Investigation Witness Statement

Name _______________________ Position __________________ Date ______

Worksite ______________________ Accident Date _________ Time _________

Thank you for helping us analyze this incident so that we can help prevent

someone from getting hurt or sick in the future. Accuracy if very important in

helping us get to the root cause of this incident.

Please describe what you saw and heard in chronological order.

What were you doing just before the incident?

What were you doing when the incident occurred?

What did you do after the incident occurred?

Please answer the following questions:

What was the condition of the tools, equipment, machinery and materials involved

in the incident?

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Parent category: Business