Witness Statement Form
Date and time when the statement was made
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Witness Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Company Name
Jobsite
Please Select
Belgrade, MT
Azure Sky, TX
Ranchland, TX
Rock Haven, OK
Bake Oven, OR
OTHER
Incident Information
Date when incident happened
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Month
-
Day
Year
Date
Time of the incident
Hour Minutes
AM
PM
AM/PM Option
Location
Type of Incident?
Injury
Near Miss
Property Damage
Motor Vehicle Accident
Environmental
Sub Contractor
Other
What is the affected body part?
Can you please explain and describe on how the incident happened? Please be specific and provide each step.
Only provide the FACTS of what happened.
Please use this field to upload photos related to the incident
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Please list down the names of anyone present during the incident
I certify that the information I provided in this form is accurate and true.
I understand that any false statements I provide can be used against me.
I understand that this document will be considered strictly confidential.
Witness Signature
Date Signed
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Month
-
Day
Year
Date
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