STATEMENT OF WITNESS TO ACCIDENT

INCIDENT IDENTIFICATION INFORMATION

NAME OF EMPLOYEE ALLEGING INCIDENT	TITLE / ROLE
SHIFT	DEPARTMENT

WITNESS STATEMENT

Your name was provided as a witness by the employee listed above. In order to complete a timely and thorough investigation of this incident, please provide the following details and submit your completed statement as soon as possible.

WITNESS NAME	WITNESS TITLE / ROLE
WITNESS ADDRESS	WITNESS PHONE
DID YOU SEE AN INCIDENT INVOLVING THE ABOVE EMPLOYEE?	YES	NO
IF NOT, HOW DID YOU LEARN ABOUT THE ACCIDENT?
IF YOU DID SEE THE ACCIDENT OCCUR:
LOCATION OF INCIDENT	DATE OF INCIDENT	TIME
PLEASE DESCRIBE WHAT YOU SAW:

NAME	SIGNATURE	DATE
WITNESS
REPORT RECEIVED BY

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