Fillable STATEMENT OF WITNESS TO AN INCIDENT (City of Providence)

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STATEMENT OF WITNESS TO AN INCIDENT (City of Providence)

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Country of origin: US
File type: PDF

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STATEMENT OF WITNESS TO AN INCIDENT
WHO IS MAKING THIS STATEMENT:
Your Name:
Department: Job Title:
Contact Information: Work phone:
Contact phone: Cell Home
Name of your foreman or supervisor:
INCIDENT INFORMATION:
Date of Incident: Time of Incident: AM PM
Name of Interviewer and/or Translator (if applicable)
INCIDENT DETAILS:
How close were you when the incident occurred (in feet)?
Did you see the incident? Yes No
Who, if anyone, was injured?
Where did it happen? (Name of street, building, office, etc.)
What happened?
What did you notice about the injured person? (such as bleeding, limping, vomiting etc.)
What complaints did the injured person make (such as where was the pain?)
What happened immediately after the incident?
Did the employee continue to work? Yes No
Was anyone else present at the time? Yes No
If yes, what were their names?
Do you have any suggestions on how to prevent this from happening again?
Witness Signature Date
Supervisor’s Signature Contact Number Date
Rev. Feb. 2019
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STATEMENT OF WITNESS TO AN INCIDENT (City of Providence)

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Completed 14 July 2020

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