Incident Witness Statement Form
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Forms for Occupation Health and Safety
OH&S 18
INCIDENT WITNESS STATEMENT FORM
Witness Information
Name: (Please Print)
Worksite Description:
Address:
City, Province:
Postal Code:
Contact Number:
Date and Time of incident: (MM,DD,YYYY)
_____________________
__________________ am pm
Location:
________________________________________________________________________________________
Type of Incident/ Injury
Other
Injury/Illness
Property
Vehicle
Potential/Near
Fire
Spill
Damage
Miss
The purpose of this statement is to establish written facts by you, the witness. Please include all observations
contributing factors leading up to the event being investigated.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
THANK YOU for your participation in this investigation. Your input is valuable to PHRD.
The PHRD is a Freedom of Information and Protection of Privacy organization; therefore, all personal information that is collected for the
purpose if Health and Safety is subject to all the rules and regulations of the Freedom of Information and Protection Of Privacy Act, Section
33(c). Only Authorized persons may access this information. Any inquiries may go to human resources department, Barrhead, Alberta. All
witness statements will be kept on file for a minimum of (3) years
OH&S 17
Received August 25, 2010
Page 1 of 1
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