PCL HSE MANUAL
Incident Investigation
Standard HSE-13-03
Witness Statement
Date statement was written*:
*
-
Month
-
Day
Year
Date Picker Icon
Time statement was written:
*
Hour Minutes
AM
PM
AM/PM Option
Name of person giving statement*:
*
Name of person taking statement*:
*
This statement is regarding (who / what)*:
*
Details (be specific and descriptive)*:
*
I declare that the statement above, which I have given to _______ has been read by (to) me. I understand the contents of this statement and I declare that it truly and correctly records the information given by me. (Fill in space with name of person taking statement.)*
*
Person Giving the Statement- Signature
*
Person Taking the Statement- Signature
*
Witness Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone*:
*
Format: (000) 000-0000.
*Required Entry into the SMC
January 2021
Rev. 04
1-2
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PCL HSE MANUAL
Incident Investigation
Standard HSE-13-03
When completing a statement (or reviewing one), the following must be included:
The date and time that the statement was written,
Name and title of person who wrote the statement
Who / what the statement is about,
The sequence of events, in chronological order,
Very specific and descriptive detail, including:
Times within the details
Names and titles of people
Specifics of what was said, rather than general comments
A 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.
January 2021
Rev. 04
2 - 2
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