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Worker Witness Statement Form

This document is a workers compensation witness statement form that collects information about workplace incidents. It asks for details like the date, location, and people involved in the incident. It also asks the witness to describe what happened, how the employee was injured, if any safety rules were broken, how to prevent similar incidents, and how the injured employee was assisted. The form gathers key facts about workplace incidents from eyewitnesses.

Uploaded by

Richard R M Thodé
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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626 views1 page

Worker Witness Statement Form

This document is a workers compensation witness statement form that collects information about workplace incidents. It asks for details like the date, location, and people involved in the incident. It also asks the witness to describe what happened, how the employee was injured, if any safety rules were broken, how to prevent similar incidents, and how the injured employee was assisted. The form gathers key facts about workplace incidents from eyewitnesses.

Uploaded by

Richard R M Thodé
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Workers Comp. Witness Statement Form


Incident Date and Time:

Incident Location:

Name of Employee In Question:

Did bodily injury result from the incident? If yes, please list the body part or parts affected:

Did horse play, inattention, neglect of safety rules, etc. contribute to the cause of this incident? Please
explain.

Did someone or something else contribute to this Incident? Please explain:

In your opinion what measures would have prevented this incident and what steps should be taken to
prevent a similar occurrence? (rules, training, etc.)

Incident Description – WHAT DID YOU SEE? (Sequence of events, task or activity engaged in, tools and
equipment involved, etc.)

Describe the response given by staff or others to the employee in question (type of aid, by whom, etc.).

Witness Name (print)

Witness Signature Date

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