Witness Statement Form

Claim Information:

Injured Employee:  	Date of Accident: _ 	Time:  	

Facility:  	Department:  	

Witness Information:

Name:     	

Date:  	

Address:  	/ Phone Number:  	

City:  	State:  	Zip Code:  	/Alt Phone Number:  	

Did you see the Accident Happen?	Yes	No	If No, What did you see?

Where did it happen?

Where were you?

Was anyone injured?	Yes	No   - If Yes, Who?   	

What type of Injury?  	

Describe exactly what happened?

Were there any other witnesses?  	

Additional Information:

Witness Signature:  	Date: