Witness Statement
Thank you for helping us analyze this incident/accident/near miss so that we can help prevent someone from getting hurt or sick in the future. Accuracy is very important in helping us get to the root cause of this. Please describe what you saw and heard in chronological order.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please explain the 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.
For 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 below.
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