Title Page
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Document No.
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Accident / Incident/ Near Miss Witness Statement
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Witness Name
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Location
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Site Manager
Section 1 - Personal Details - Dickie and a Moore Representative
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Select date
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Name
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Position
Section 2 - Personal Details - Witness Information
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Photograph of Witness
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Member of Public
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Name
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Address
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Date of Birth
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Age
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National Insurance Number
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Employer
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Occupation
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Contact Details
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How long have you worked for this Employer?
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How long have you worked on this Dickie and Moore project/site?
Section 3 - Incident Information
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Where on the premises / site did the incident take place?
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Describe what happened / what you saw / what you heard, in your own words
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Who else was in the area, and what were they doing at the time?
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What were you doing immediately before, and what did you do during & immediately after, the incident?
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Did you report the incident?
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If YES, when did you report it, and who did you report it to?
Section 4 - Confirmation
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By signing and dating this document, I confirm that the content is both factual and accurate, and that the content has been fully discussed with the Dickie and Moore representative named in Section 1, on the date below, to ensure my understanding of the content and my agreement of its accuracy
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Witness Signature
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Select date
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Dickie and Moore Representative Signature
