HTML Preview Service Witness Statement page number 1.
State of Nebraska
FORM Dept. of Administrative Services
WS Risk Management Division
Witness Statement
Witness Name: Employee Involved:
Witness Address: Witness Home Telephone:
Witness Employer: Witness Alternate Phone:
Witness Statement
On ____________________(date), 20__ (year), at approximately _____________ am/pm,
I was in or at _____________________________________ (clearly state your location)
when an accident involving the above employee is alleged to have occurred.
Check Only One Box Below
I saw the accident. The accident occurred in the following manner: (please describe in as
much detail as possible)
I did not see the accident. Information given to me by _________________ (name)
indicates the accident occurred as follows:
(please describe in as much detail as possible)
I know nothing whatsoever about the occurrence.
Witness Signature: Date: