Worker Witness Statement Form

Welcome! Puedes responder en espanol!

1. Witness Name: *This question is required.

First/Last Name - Su Nombre

Name of the injured - Nombre del empleado lesionado

Your Phone Number - Numero de telefono

What is your job title? Cual es su profesion?

2. Who is your supervisor?
Nombre del supervisor (jefe) este dia? *This question is required.

3. Date of Incident:
Fecha? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. What time did the incident occur?
A que hora ocurrio el incidente? *This question is required.

5. What day are you making this report?
Cual es la fecha hora? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

6. Location of Incident:
Donde ocurrio? *This question is required.

7. Please describe the accident from start to finish - Describe el accidente de principio a fin. *This question is required.

How were you involved?
Como estuviste involucrado?

9. Was any third party Involved? If yes, explain
Hubo algun tercero involucrado? Explique *This question is required.

10. Describe the work conditions including weather, equipment malfunctions, anything unusual?
Describa las condiciones de trabajo, incluido el clima, el mal funcionamiento del equipo, cualquier cosa sospechosa? *This question is required.

11. Anything else you would like to add?
Cualquier otra cosa que le gustaria discutir? *This question is required.

12. By signing you agree that all your statements are true to the best of your knowledge.
Cuando firmas aqui aceptas que todo lo que has dicho es verdad.
*This question is required.

Clear

Signature of

13. Please select Site Admin Email or Foreman that is on site with you.
Seleccione el correo electrónico del administrador del sitio o del Foreman *This question is required.

14. Any Photos you want to add?
Tienes Photos?

File: {{filename}} delete

Worker Witness Statement Form

ACCIDENT/INCIDENT WITNESS STATEMENT FORM