Preview Incident Witness Statement

Department of Environmental Health

& Safety

INCIDENT WITNESS STATEMENT

Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as

soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor. 

EOSMS 108-3 Incident Witness Statement 02/02/2015 Page 1 of 1

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To be completed by accident witness

Injured employee First

Name

Injured employee Last

Name

Witness First Name Witness Last Name

Witness Home address: Tel #

City State Zip Code

Witness Job Title

Witness

Department

Witness Supervisor Name

Supervisor

Tel #

Employment Type

 Faculty

 Staff

 Student

 Contractor

 Others_________

Employment Category

 Regular full time

 Regular part time

 Seasonal

 Temporary

Length of Employment

 1-6 mos.

 6 mos. – 1 yr.

 1 yr. – 5 yrs.

 5 yrs. (or more)

Describe the incident

Date of Incident

Time of the

incident

Shift

 1

 2

 3

Location of the Incident

(Address)

Specific Location of the incident

(e.g office, mechanical room, shop)

Did the incident involve property

damage?

 Yes

 No

Was a motor vehicle involved in this incident?

 Yes

 No

Affected body Part:

 Head/face  Eye  Neck/shoulder  Arms/elbow  Right Hand  Left Hand  Wrist/Head  Rib

 Fingers  Chest/lower trunk  Hip  Back  Leg/knee  Foot/ankle  Toes

 Other

________

Describe, step-by-step, how the incident occurred:

What would you recommend to prevent this accident from recurring:

Witness Signature

Date

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