Witness Statement Form

Witness Statement Form
Name*
Date*

MonthDayYear
Date
Explanation of event*
What were you doing just before the event occurred?*
What were you doing while the event occurred? *
What did you do after the event occurred? *
What was the condition of the tools, equipment, machinery, and materials involved in the event? *
What was the work environment like? Was it very cold , wet, slippery etc., *
What was the type and condition of the Personal Protective Equipment (PPE) being used by the injured person when the event occurred? *
What was the instruction or training you and others received like on the task being performed when the event occurred? Please describe the training you received.*
Example: If a fall occurred, then Fall Protection training would be training received to prevent such an event.
Please list the full names of anyone else who witnessed or heard the event.*
How do you think we can prevent this in the future?*
Please upload any photos or documentation regarding this accident

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