Incident Statement Form

STATEMENT FORM
Injury Management Standard HSE-14-02
Statement
Date and time statement was written

MonthDayYear
Date
Name and title of person giving statement
This statement is regarding (who / what)
Details (be specific and descriptive):
I declare that the statement above, which I have given to read back (to) me.
I understand the content of this statement and I declare that it truly and correctly records the information given by me.
Signature
DD/MM/YY
Street
City
State/Province
Zip Code/Postal Code
Home
Work
PCL HSE MANUAL
Injury Management Standard HSE-14-02

When completing or reviewing a statement, the following must be included:
- The date and time the statement was written
- Who wrote the statement, including their title
- Who / what the statement is about
- The sequence of events, in chronological order
- Very specific and descriptive detail, including: oTimes within the details oNames and titles of people oSpecifics of what was said, rather than general comments oA sequence of events that are accurate and include all information. The more descriptive the statement the better
Do not include any personal or subjective comments on a statement.
DATE OF BIRTH

MonthDayYear
Date
Status In Trade
Years of Experience
Should be Empty:

Statement