Witness Statement Form

Required

Incident Information

Enter your Email Address:required

Names of Injured Employee(s) Involved:required

Date of Incident:required

Must contain a date in M/D/YYYY format

Time of Incident:required

Witness Information

Name of Witness:required

Work Location:required

Telephone (Work):required

Telephone (Personal):required

Home Address:required

Work Relationship to Party(ies) Affected by Incident:required

Witness Statement

Where were you at the time of the incident?required0 / 5000

What were you doing at the time of the incident?required0 / 5000

What did you observe?required0 / 5000

Additional Comments:0 / 5000

Electronic Signaturerequired

By selecting this box you consent to sign this form with an electronic signature.

Witness Signature:required

First Name

Middle (optional)

Last Name

Today's Date:required

Must contain a date in M/D/YYYY format

Questions? Need Help?

Contact your Safety Support Specialist.

Jennifer Flores

SAFETY COMPLIANCE OFFICER

Office: 559-730-7514
Extension: 11382
Main: (559) 730-7300

Supervisor's Injury/Illness Investigation Report

The Supervisor's Injury/Illness Ivestigation Report is to be completed by the Supervisor. This is a confidential report for HRD use.

View the Supervisors Report

Workplace Violence Reporting Form

This form is to be used by employees that have identified an incident, threat or concern related to workplace violence.

View the Workplace Violence Reporting Form

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