Witness Statement Form - Health & Safety Resources

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HEALTH & SAFETY
Resources
Witness Statement Form
(HR-8-R2)
Date of injury/incident:
_________________________________________________________________
Name of witness:
_________________________________________________________________
Date:
_________________________________________________________________
Name of interviewer:
_________________________________________________________________
Details of interview:
_________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature of witness:
_________________________________________________________________
Signature of
interviewer:_________________________________________________________________

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