Incident Witness Statement
To help EHS management and incident investigators best understand what took place, try to use objective language to describe the events. For example: “Dog moved towards victim with teeth bared” as compared to “dog looked mad”.
Unique ID
Name
First Name
Last Name
Title/Position
EHS Staff/Volunteers
Supervisor Email (individual involved in incident)
*
example@example.com
Please state your involvement in the incident
Individual Reporting incident
Individual Affected by incident (e.g. victim)
Witness
Please describe in detail the events of the incident from start to finish
Note anything unusual you observed before or during the incident
How could the incident have been prevented?
Additional comments/ observations
Signature: I declare that theinformation, provided on this report, is accurate and true.
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: