Fillable Towson University office of human resources Worker's Compensation Witness Statement

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Towson University office of human resources Worker's Compensation Witness Statement

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October 2019
Office of
Human Resources
Human Resources Towson University - 8000 York Rd, Towson MD 21252 - 410-704-2162 - towson.edu/hr
Workers’
Compensation
Witness Statement
Injured Employee Name (Last, First, MI)
Witness Name
Witness Empl ID (If applicable)
Witness Location/Department
Witness Phone
Witness Email
Date of Injury
How Did You Learn of the Incident?
Activity Employee Was Engaged In At Time of Injury
Location Where Incident Took Place
Activity You Were Engaged in at Time of Injury
Did You Speak With Anyone About the Incident? If So, Who?
What Did You Personally Witness? Describe Sequence of Events and Any Objects or Substances Which May Have Contributed
Your Reaction/ Steps Taken After the Event
Type of Injury and Body Parts Affected
Treatment Received
How Can This Type of Injury or Incident Be Prevented in the Future?
Any Other Relevant Information?
I attest that all the above information is true and accurate to the best of my knowledge.
Witness Signature (Do Not Type Name) Date
Submit to the Office of Human Resources (OHR) within 24 hours of the report of an injury.
Fax 410-704-6320, email leavebenefits@towson.edu
.
If you have any questions, please call the OHR at 410-704-2162.
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Towson University office of human resources Worker's Compensation Witness Statement

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Completed 20 December 2019

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