Form Sorm 74f - Witness Statement Form - State Office Of Risk Management

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WITNESS STATEMENT
MUST BE TYPED OR PRINTED
Injured Employee Name: _______________________________ Date of Injury: ________________________
SORM Claim Number: _________________ Statement Taken By: ___________________________________
Witness Name: _____________________________________________________________________________
Witness Email Address: ______________________________________________________________________
Residence Address: _________________________________________________________________________
Primary Telephone: __________________________ Secondary Telephone: __________________________
Witness Employer: ____________________________________________
On ________________, at about ____________ in the
a.m. /
p.m., I was in or at
________________________ when an accident involving the above employee is reported to have occurred.
SELECT CHOICE A, B, OR C BELOW:
A.
I saw the incident. The accident occurred in the following manner:
Other pertinent information and source:
B.
I did not see the incident. Information given to me by (name of person):
Indicate how i t occurred:
Other pertinent information and source:
C.
I know nothing whatsoever about the incident.
Signature: _______________________________________
Date: _________________________
SORM 74f Rev. 3/16

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