Employee Statement Form
Please complete this form to provide a detailed account of the event or incident.
Client Name
*
Date
*
-
Month
-
Day
Year
Date
Date of Shift
*
-
Month
-
Day
Year
Date
Location of Event
*
Describe fully what occurred
*
Did anyone else witness what happened?
*
Yes
No
If yes, who? (witness to what happened)
Did you interact with anyone during or after the event?
*
Yes
No
If yes, who? (interaction during/after event)
What was said to you?
Did you report the incident?
*
Yes
No
If yes, to whom? (incident reported)
Was anyone injured?
*
Yes
No
If yes, who? (injured person)
Please describe the location and how the injury occurred
Name Printed
*
Signature
*
Witness Name
Submit Statement
Submit Statement
Should be Empty: