Non-Employee Incident And Witness Statement Form

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Non-Employee Incident and Witness Statement Form
Directions:
• This form should be filled out
immediately
after first-aid has been performed.
• Upon completion, this form should be given to the Department Supervisor/Department
Head within 24 hours of the incident. A copy should also be kept on file at the facility for
review and possible further distribution.
• First page to be filled out by City Employee.
• Second page to be filled out by a witness of the incident if applicable.
• Third page to be filled out by department head.
________________________________________________________
_________________
Name of Injured Person
Age
______________________________________________________________________________
Street Address
City of Menasha
State
Zip
______________________________________
__________________________________
Home Telephone Number/Cell Phone Number
Work Telephone Number
______________________________________
_______________________AM PM
____
Date of Incident
Time of Incident
(circle one)
Describe How the Incident Occurred:________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Description of Injury:____________________________________________________________
______________________________________________________________________________
Was First Aid Given?_______________________ By Whom?_____________________________
Describe First-Aid Given:__________________________________________________________
______________________________________________________________________________
Was injured person transported from the area by emergency medical personnel?____________
If yes, to where and by whom (Name, Address, Telephone Number):______________________
______________________________________________________________________________
Does the injured person have health insurance? Yes or No? If yes, who is the carrier?
______________________________________________________________________________
Name, address and telephone number of person notified (parent and/or guardian if injured
person is minor):________________________________________________________________
______________________________________________________________________________
______________________________________________________
Signature and Title of person filling out form
(1)
Revised (2-08)

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