Sample Accident Investigation Witness Statement Page 2

What was the work environment like? Was it very hot or cold, wet, slippery,

windy, etc.?

What was the type and condition of the Personal Protective Equipment (PPE)

being used by the injured person when the incident occurred?

What was the instruction or training you and others received like on the task being

performed when the incident occurred? Please describe the training you received.

What was the direction of travel, fall, or final resting place of the vehicle or

equipment and individual involved in the accident (draw a diagram, if

appropriate.)

Who else witnessed or heard the incident?

How do you think we can prevent this incident in the future?

I certify that statement is true and accurate to the best of my recollection.

_________________________________________

_____________________

Signature

Date

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