Witness Statement

State of Nebraska

FORM

Dept. of Administrative Services

Risk Management Division

Witness Statement

Witness Name:

Employee Involved:

Witness Address:

Witness Home Telephone:

Witness Employer:

Witness Alternate Phone:

Witness Statement

On ____________________(date), 20__ (year), at approximately _____________ am/pm,

I was in or at _____________________________________ (clearly state your location)

when an accident involving the above employee is alleged to have occurred.

Check Only One Box Below

I saw the accident. The accident occurred in the following manner:

(please describe in as

much detail as possible)

I did not see the accident. Information given to me by _________________ (name)

indicates the accident occurred as follows:

(please describe in as much detail as possible)

I know nothing whatsoever about the occurrence.

Witness Signature:

Date:

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