Incident Witness Statement printable pdf download

Incident Witness Statement

INCIDENT WITNESS STATEMENT

Department of Environmental Health

& Safety

Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as

soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor.

EOSMS 108-3 Incident Witness Statement

02/02/2015

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To be completed by accident witness

Injured employee First

Injured employee Last

Name

Witness First Name

Witness Last Name

Witness Home address:

Tel #

City

State

Zip Code

Witness

Witness Job Title

Department

Supervisor

Witness Supervisor Name

Tel #

Employment Type

Employment Category

Length of Employment



Faculty

Regular full time

1-6 mos.



Staff

Regular part time

6 mos. – 1 yr.



Student

Seasonal

1 yr. – 5 yrs.



Contractor

Temporary

5 yrs. (or more)



Others_________

Describe the incident

 1

 2

Time of the

Date of Incident

Shift

 3

incident

Location of the Incident

Specific Location of the incident

(Address)

(e.g office, mechanical room, shop)



Did the incident involve property

Yes

Was a motor vehicle involved in this incident?



damage?

Affected body Part:

 Head/face

 Eye

 Neck/shoulder  Arms/elbow

 Right Hand

 Left Hand

 Wrist/Head

 Rib

 Fingers

 Chest/lower trunk

 Hip

 Back

 Leg/knee

 Foot/ankle

 Toes

 Other

________

Describe, step-by-step, how the incident occurred:

What would you recommend to prevent this accident from recurring:

Witness Signature

Date

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Incident Witness Statement

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