SCMV Witness Statement

Witness Statement
CONFIDENTIAL - this statement will only be shared with personnel involved in the incident investigation, you may be contacted to verify the information provided.
Witness Name:*
Witness Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Witness Email Address (confidential) *
Supervisor's Name *
YesNo
Department *
Position *
Company*
Work Site*
What event is this related to?*
Date/Time Statement Taken *

MonthDayYear
Date
Hour MinutesAM/PM Option
(Old) Location Where the Incident Occurred? *

Please provide address or description of the location where the incident occurred

Street Address Line 2

CityState / Province

Postal / Zip Code
Alexander HotelBlack Swift LodgeGrey Wolf LodgeMLV 1100/1200Mountain Lynx LodgeMultiple SitesRVSpring Creek Gate Road ExtensionTMV 900/1000Other
Date/Time of Incident:*

YearMonthDay

Hour MinutesAM/PM Option
When completing this statement, be sure to include all events and factors that led to this accident/incident/loss. Include actions taken during and after.
Incident Description *
Include relevant details such as location, lead-up to event, what you heard, saw, smelled, etc.
Image(s) or sketch(s) of incident

Cancelof
Witness Signature:*

Clear
Should be Empty: