Non-Employee Incident And Witness Statement Form Page 2

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VICTIM/WITNESS STATEMENT
Name, Addresses and Telephone Numbers of ALL Witnesses:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Description of Incident: (Please indicate where the incident occurred, what you saw and heard
at what time the incident occurred. Also indicate any factors that may have contributed to the
incident. Please sign your name after the statement and use the back side if needed.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Attach additional pages if needed.
____________________________________________________
_________________
Non-employee Injured party / Witness Signature
Date
(2)
Revised (2-08)

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