Form WS "Witness Statement Form" - Nebraska

What Is Form WS?

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

Form Details:

  • The latest edition provided by the Nebraska Department of Administrative Services;
  • 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 printable version of Form WS by clicking the link below or browse more documents and templates provided by the Nebraska Department of Administrative Services.

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Download Form WS "Witness Statement Form" - Nebraska

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State of Nebraska
FORM
Dept. of Administrative Services
WS
Risk Management Division
Witness Statement
Witness Name:
Employee Involved:
Witness Address:
Witness Home Telephone:
Witness Employer:
Witness Alternate Phone:
Witness Statement
On ____________________(date), 20__ (year), at approximately _____________ am/pm,
I was in or at _____________________________________ (clearly state your location)
when an accident involving the above employee is alleged to have occurred.
Check Only One Box Below
I saw the accident. The accident occurred in the following manner:
(please describe in as
much detail as possible)
I did not see the accident. Information given to me by _________________ (name)
indicates the accident occurred as follows:
(please describe in as much detail as possible)
I know nothing whatsoever about the occurrence.
Witness Signature:
Date:
State of Nebraska
FORM
Dept. of Administrative Services
WS
Risk Management Division
Witness Statement
Witness Name:
Employee Involved:
Witness Address:
Witness Home Telephone:
Witness Employer:
Witness Alternate Phone:
Witness Statement
On ____________________(date), 20__ (year), at approximately _____________ am/pm,
I was in or at _____________________________________ (clearly state your location)
when an accident involving the above employee is alleged to have occurred.
Check Only One Box Below
I saw the accident. The accident occurred in the following manner:
(please describe in as
much detail as possible)
I did not see the accident. Information given to me by _________________ (name)
indicates the accident occurred as follows:
(please describe in as much detail as possible)
I know nothing whatsoever about the occurrence.
Witness Signature:
Date: