Language
English (US)
Español
Employee Statement - Incident / Accident / Complaint
Be specific regarding time, place, how the event occurred, who was present. Refer to persons by their names (avoid “she”, “he”, “they”, etc.) Be sure to include to who it was reported, when and any relevant information.
Date of Occurrence:
*
/
Month
/
Day
Year
Date
Date of Written Statement:
*
/
Month
/
Day
Year
Date
Client's Name:
*
Employee's Name:
*
Be specific regarding time, place. how the event occurred. who was present. Refer to persons by their names (avoid "she", "he", "they", etc.) Be sure to include to who it was reported. when and any relevant information.
*
Employee Signature:
*
Employee's Email:
*
example@example.com
Human Resource Signature:
Preview PDF
Submit
Should be Empty: