"Incident Witness Statement Form - Kennesaw State University"

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INCIDENT WITNESS STATEMENT
Department of Environmental Health
& Safety
Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as
soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor.
 
EOSMS 108-3 Incident Witness Statement
02/02/2015
Page 1 of 1
To be completed by accident witness
Injured employee First
Injured employee Last
Name
Name
Witness First Name
Witness Last Name
Witness Home address:
Tel #
City
State
Zip Code
Witness
Witness Job Title
Department
Supervisor
Witness Supervisor Name
Tel #
Employment Type
Employment Category
Length of Employment
Faculty
Regular full time
1-6 mos.
Staff
Regular part time
6 mos. – 1 yr.
Student
Seasonal
1 yr. – 5 yrs.
Contractor
Temporary
5 yrs. (or more)
Others_________
Describe the incident
 1
 2
st
nd
Time of the
Date of Incident
Shift
 3
rd
incident
Location of the Incident
Specific Location of the incident
(Address)
(e.g office, mechanical room, shop)
Did the incident involve property
Yes
Yes
Was a motor vehicle involved in this incident?
damage?
No
No
Affected body Part:
 Head/face
 Eye
 Neck/shoulder  Arms/elbow
 Right Hand
 Left Hand
 Wrist/Head
 Rib
 Fingers
 Chest/lower trunk
 Hip
 Back
 Leg/knee
 Foot/ankle
 Toes
 Other
________
Describe, step-by-step, how the incident occurred:
What would you recommend to prevent this accident from recurring:
Witness Signature
Date
Page 1 of 1 
INCIDENT WITNESS STATEMENT
Department of Environmental Health
& Safety
Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as
soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor.
 
EOSMS 108-3 Incident Witness Statement
02/02/2015
Page 1 of 1
To be completed by accident witness
Injured employee First
Injured employee Last
Name
Name
Witness First Name
Witness Last Name
Witness Home address:
Tel #
City
State
Zip Code
Witness
Witness Job Title
Department
Supervisor
Witness Supervisor Name
Tel #
Employment Type
Employment Category
Length of Employment
Faculty
Regular full time
1-6 mos.
Staff
Regular part time
6 mos. – 1 yr.
Student
Seasonal
1 yr. – 5 yrs.
Contractor
Temporary
5 yrs. (or more)
Others_________
Describe the incident
 1
 2
st
nd
Time of the
Date of Incident
Shift
 3
rd
incident
Location of the Incident
Specific Location of the incident
(Address)
(e.g office, mechanical room, shop)
Did the incident involve property
Yes
Yes
Was a motor vehicle involved in this incident?
damage?
No
No
Affected body Part:
 Head/face
 Eye
 Neck/shoulder  Arms/elbow
 Right Hand
 Left Hand
 Wrist/Head
 Rib
 Fingers
 Chest/lower trunk
 Hip
 Back
 Leg/knee
 Foot/ankle
 Toes
 Other
________
Describe, step-by-step, how the incident occurred:
What would you recommend to prevent this accident from recurring:
Witness Signature
Date
Page 1 of 1