Incident Witness Statement

zzz - Submit - Incident Witness Statement

Employee Incident Witness Statement Form

Name of Employee: *

The one involved in the incident.

Witness Statement

Your name has been given as a witness to an incident alleged by the above individual. Through your cooperation, information can be obtained to complete the investigation of this incident. Therefore, it will be appreciated if you will answer each of the following questions and promptly return your completed statement.

Your Name: *

Your Occupation: *

Your Address: *

Your Address:

City

State/Province

Zip/Postal

Country

Your Phone Number *

Did you see an accident involving the above employee? *

Yes

If not, how did you learn about the accident? *

If you did see an accident occur:

Date of accident: *

Time of accident: *

Describe what you saw: *

If you are human, leave this field blank.