PCI CA Witness Injury Statement

WORKERS’ COMPENSATION INJURY WITNESS STATEMENT
Witness Statement/Declaracion de Testigo WitnessStatement/DeclaraciondeTestigo

Please complete the following in your own words /Porfavor completa lo siguente en sus palabras
PCI Location*
Witness Name / Nombre de testigo

First NameLast Name
Social Security Number Seguro Social
Occupation / Ocupacion
Phone Number Numero de telefono
Please enter a valid phone number.
Date of injury Fecha del dano

MonthDayYear
Date
Time of injury Hora del dano
Location where injury occurred Donde ocurio el dano
Describe what you saw/ Describir lo que usted observio
In your opinion, what body parts were injured?/ En su opinion, quales partes del cuerpo se lastimo?
Who or what caused the injury/accident? / Que cause el incidente/lastimada?
Did anything appear suspicious about the incident/injury? Algo de incidente/lastimada paresio sospechoso?
Was there anything that could have been done to prevent the injury? Habia algo que Ud. pudo hacer para evitar el dano?
Witness Signature Firma del testigo

Clear
Date Fecho de hoy

MonthDayYear
Date
Should be Empty: