CTMD Form 1-6A "Serious Incident Report Witness Statement" - Connecticut

What Is CTMD Form 1-6A?

This is a legal form that was released by the Connecticut Military Department - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Connecticut Military Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of CTMD Form 1-6A by clicking the link below or browse more documents and templates provided by the Connecticut Military Department.

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Download CTMD Form 1-6A "Serious Incident Report Witness Statement" - Connecticut

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CTMD Form 1-6a
(Rev. 7/2015)
CONNECTICUT MILITARY DEPARTMENT
SERIOUS INCIDENT REPORT
WITNESS STATEMENT
PURPOSE: To document observations and statements by witnesses in support of CTMD Form 1-6
(Serious Incident Report).
AUTHORITY: Connecticut General Statutes Section 27-6a, 27-7, 27-17, 27-18, 27-61, 27-67, 31-284a
& 31-309.
INSTRUCTIONS: Witness statements should be taken as soon after an incident as possible. First
priority for commanders is to ensure individuals are safe and medically treated (if necessary).
Secondarily is to ensure the incident is properly documented in order to ensure affected individuals
receive proper follow-up support and to review the circumstances around the incident to take
remedial action to ensure it does not happen again.
• WITNESS INFORMATION: Witnesses to a serious incident are not limited to active members
reported on CTMD Form 1-1. Any individual who is a witness to an incident should be
encouraged to make a statement.
• INCIDENT INFORMATION: The date, time, location and name of the individual must be
consistent with the information provided on CTMD Form 1-6.
• STATEMENT: The witness will provide a narrative statement of what they saw to the best of
their knowledge as they saw events transpire.
• INFORMATION REPORTING PROCEDURES: At a minimum, the Assistant Adjutant General
and the Military Administrative & Programs Officer need to be informed in addition to the
CTMD Personnel office and the Third Party Administrator Intake Center.
SEND THIS FORM & SUPPORTING DOCUMENTATION TO:
Connecticut Military Department
Human Resources Manager
360 Broad Street Room #141
Hartford, Connecticut, 06105-3706
(860) 548-3218 (fax)
Page 1 of 2
CTMD Form 1-6a
(Rev. 7/2015)
CONNECTICUT MILITARY DEPARTMENT
SERIOUS INCIDENT REPORT
WITNESS STATEMENT
PURPOSE: To document observations and statements by witnesses in support of CTMD Form 1-6
(Serious Incident Report).
AUTHORITY: Connecticut General Statutes Section 27-6a, 27-7, 27-17, 27-18, 27-61, 27-67, 31-284a
& 31-309.
INSTRUCTIONS: Witness statements should be taken as soon after an incident as possible. First
priority for commanders is to ensure individuals are safe and medically treated (if necessary).
Secondarily is to ensure the incident is properly documented in order to ensure affected individuals
receive proper follow-up support and to review the circumstances around the incident to take
remedial action to ensure it does not happen again.
• WITNESS INFORMATION: Witnesses to a serious incident are not limited to active members
reported on CTMD Form 1-1. Any individual who is a witness to an incident should be
encouraged to make a statement.
• INCIDENT INFORMATION: The date, time, location and name of the individual must be
consistent with the information provided on CTMD Form 1-6.
• STATEMENT: The witness will provide a narrative statement of what they saw to the best of
their knowledge as they saw events transpire.
• INFORMATION REPORTING PROCEDURES: At a minimum, the Assistant Adjutant General
and the Military Administrative & Programs Officer need to be informed in addition to the
CTMD Personnel office and the Third Party Administrator Intake Center.
SEND THIS FORM & SUPPORTING DOCUMENTATION TO:
Connecticut Military Department
Human Resources Manager
360 Broad Street Room #141
Hartford, Connecticut, 06105-3706
(860) 548-3218 (fax)
Page 1 of 2
CTMD Form 1-6a
(Rev 7/2015)
CONNECTICUT MILITARY DEPARTMENT
SERIOUS INCIDENT REPORT
WITNESS STATEMENT
WITNESS INFORMATION
Last Name, First Name, MI:
Rank:
Unit:
Street, City, State & Zip Code:
INCIDENT INFORMATION
Date:
Time:
Location:
Name of individual(s) involved:
STATEMENT (narrative description of incident)
ACKNOWLEDGMENT
I attest that the information provided on this statement is true and correct to the best of my knowledge.
Signature of Witness
Date
CERTIFICATION
I certify that the individual making this statement was present at the incident and is of sound mind and good judgement.
Signature of Officer
Date
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