Workers' Compensation Accident/injury Investigation Witness Statement Form printable pdf download

Workers' Compensation Accident/injury Investigation Witness Statement Form

DEPARTMENT OF PUBLIC INSTRUCTION

Ed. Services for the Deaf and Blind

WORKERS COMPENSATION

ACCIDENT/INJURY INVESTIGATION

WITNESS STATEMENT FORM

DIRECTIONS: DO NOT TYPE. MUST BE HANDWRITTEN BY EMPLOYEE.

PLEASE WRITE CLEARLY. FORM MUST CONTAIN AN

ORIGINAL SIGNATURE OF THE EMPLOYEE SUPPLYING

STATEMENT.

EMPLOYEE NAME: ________________________________________________________

POSITION TITLE: __________________________________________________________

WORK LOCATION: ___N.C. School for the Deaf _________________________________

STATEMENT: (Use additional paper or back of form if necessary)

___________________________________________________________________________

Please list any witnesses or individuals who may have information relative to this

investigation. _______________________________________________________________

___________________________________________________________________________

I understand this statement will be considered part of the official investigation and that I may

be called on to testify or provide written or verbal clarifying statements. The statement I have

provided is an accurate account of the case to the best of my knowledge. I also understand

that this is a confidential matter and that I will not discuss any portion of the investigation

with anyone other than the investigators. Discussing this investigation with anyone other then

the investigators may result in disciplinary action up to and including dismissal.

___________________________________________________________________________

Signature

Date

Rev. 1/18/2012

Workers' Compensation Accident/injury Investigation Witness Statement Form