Title Page
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Site conducted
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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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Allma Site Supervisor
Section 1 - Personal Details - Allma Constuction Representative
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Date & Time
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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 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 Allma Construction 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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Allma Construction Representative Signature
