Witness Statement - Smith & Associates

IT IS IMPORTANT THAT THE WITNESS' STATEMENT INCLUDES ONLY FIRST-HAND KNOWLEDGE

Company Name *

Employee Name *

Your Name *

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your Phone *

Your Email Address: *

Email

Confirm Email

Please provide YOUR account of the events that occured on: *

Where were you when the accident took place? *

Were there other employees around who might have seen the accident occur? *

Who? *

What activity was being performed prior to the accident? *

What materials, equipment, or conditions were involved? Include all contributing factors. *

What happened? *

Did you observe why the accident happened? List unsafe conditions or unsafe acts. *

To the best of your knowledge, was there previously known or reported problems, or conditions associated with the employee or accident? If so, please explain. *

Is there anything else you can add in order to prevent this type of accident from occurring in the future? Anything else you think that the employer should be aware of? *

Signature

Clear Signature

Date *

Please prove your a human. *

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