CALIFORNIA LUTHERAN UNIVERSITY
Injured Person’s Witness Statement
Name of Witness: Date:
Assigned Department:
Employee ID #:
Name of Injured Person: Date of Injury:
Describe what the employee was directly doing at the time of the incident and from your observation describe how the
incident occurred including: activity performed, tool/equipment, others in the area, personal protective equipment,
location prior to the incident, actions taken during and following the incident, etc.:
List all equipment being used when the incident occurred:
Could this injury/incident have been prevented? Yes No
If yes, what recommendations do you have that could have prevented this incident?
I state the above is true and correct to the best of my knowledge.
Signature of Injured Person Date
Recvd: ___________________
Feb 2014
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