Witness Statement (Page 2 of 2) in pdf

Instructions

Witness Statement

Required:

Immediately after receiving notice of any injury, the Claims Coordinator should determine the names,

addresses, and telephone numbers of all witnesses to the incident. A statement should be taken from

each witness and forwarded to SORM.

Filing Deadline:

The form must be received by SORM not later than the 5th calendar day after the first notice of injury is

reported to the agency.

Completed by:

This form should be completed by the person giving the statement with assistance from the Claims

Coordinator.

Instructions:

1. Except for the witness signature, the statement should be typewritten, if possible. If it must be

handwritten, PLEASE PRINT to ensure legibility.

2. Please provide the SORM claim number, if known.

3. The witness may have actually seen the incident or may have acquired knowledge about the

accident from another source. The witness information may relate to how the incident occurred

or to something else that is relevant. Check the first or second box and fill in the blanks

following those boxes, as appropriate. Be specific and complete. Sometimes you will be given a

witness name but, when asked, denies any knowledge of the incident. In such a case the third

box should be checked.

4. If the space provided on the form is insufficient please attach additional sheets. Be as specific

and complete as possible.

Distribution:

The Claims Coordinator shall retain the original for the agency file and fax or mail a copy to:

State Office of Risk Management

PO Box 13777

Austin, TX 78711

Fax: (512) 3709025

Notice: With few exceptions, an individual is entitled, upon request, to be informed about the information a state governmental body collects about the

individual. Under Sections 552.021 and 552.023 of the Government Code the individual is entitled to receive and review the information and under

Section 559.004 of the Government Code the individual is entitled to have the state governmental body correct any information about the individual that

is incorrect.

SORM74 Rev 07/09

Witness Statement Page 2

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