Laserfiche WebLink
Accident Witness Statement <br />(To be completed by accident wimess) <br />Injured employee's name: <br />Last First Middle <br />Name of witness: <br />Job title of wimess: <br />Home address of wimess: <br />How long employed here? <br />State: _Zip Code: <br />Location of accident: <br />Adtlreas/Namao bui ding Area beUlroom, elo. <br />Date ofaccident: <br />Time ofaccident: <br />Describe fully how accident occurred: (including events that occurred immediately before the accident): <br />Describe bodily injury sustained (be specific about body parts) affected): <br />Recommendation on how to prevent this accident <br />Name of W imesse's Supervisor: Ph# <br />Last Flrst <br />Signature of Witness: <br />Date: <br />zo4e mros <br />Farm may be copied as needed <br />T <br />