Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 8
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9Workers’ Compensation Witness Report Form
Name of injured employee: _______________________________________________
Name of witness: _______________________________________________________
Telephone # of Witness_________________________________________________
Location where incident occurred: __________________________________________
Date of incident: ______________________
Time of incident: _________________
1. What were you (the witness) doing at the time of the incident?
____________________________________________________________
2. How and when did you become aware of the incident?
____________________________________________________________
3. What did you hear at the time of the incident?
____________________________________________________________
4. Describe what you saw at the time of the incident:
____________________________________________________________
5. Who else was present?
____________________________________________________________
6. Please relate any additional information you have pertaining to the incident:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Witness’s signature: _________________________ Date signed: _______________
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Parent category: Business