Witness — Injury Statement

Complete as soon as possible following a witnessed workplace incident.

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Witness - Injury Statement r.3 fillable.pdf

Incident Information

Date of Incident *

Time of Incident

Location of Incident *

Name of Injured Person *

Witness Information

Witness Full Name *

Job Title

Department

Phone *

Street Address

City / State / Zip

Presence at Incident

Relationship to Injured Person

Were You Present at Time of Incident? *

Did You See the Incident Occur?

Approximate Distance from Incident

What Were You Doing at the Time of the Incident?

Witness Statement

Describe What You Saw *

Contributing Factors Observed

Safety Compliance Observations

Was PPE Being Used?

Were Safety Procedures Being Followed?

PPE Details (if applicable)

Procedure Details (if applicable)

Response & Assistance

Did You Assist the Injured Person?

Was First Aid Administered?

Were Emergency Services Called?

Describe Assistance Provided

Additional Information

Other Witnesses (if known)

Additional Comments

Certification

I certify that the information provided in this statement is true and accurate to the best of my knowledge and recollection.

Witness Signature (Full Name) *

Date *