Accident/incident Investigation Report Page 3

WITNESS STATEMENT FORM

WITNESS NAME: __________________________ WITNESS EMPLOYER: __________________________

ADDRESS: _________________________________________________________________________________

PHONE: ____________________________________________________________________________________

AGE: ______________________________________ OCCUPATION: __________________________________

BRIEF DESCRIPTION OF ACCIDENT/INCIDENT

RELATIONSHIP TO INJURED PARTY

Immediately before the accident, what did you see? Did you notice the injured employee doing anything

wrong? Did you warn them? Where were you at? How far away? What did you see?

During the accident, what did you see?

Immediately after the accident, what did you see?

Have you spoken with anyone else concerning this incident?

Additional Comments:

Witness

Date

Investigator

Date

Interpreter

Date

if you run out of room, use the back of this page

Sample witness statement form

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Parent category: Business