Acorn Industrial Witness Statement for Accident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Date and Time of Accident

  Date

• Job Number

• Job Name

• Location of Accident (Be specific)

• Photos of area, injury, equipment, etc.

  Media

Employee(s) Involved in Accident

• Add Employee

Employee Name

• Employee Name

Witness(s)

• Add Witness

Witness

• Witness Name

• Witness Address and Phone Number

• Witness at the time of accident

• First knowledge of accident (what drew your attention)

• Where was employee at time of accident

• Detailed description of accident (supply any detail you can, even if you believe it had no relevance to the accident)

• Was the <injured> employee working with any tool(s), machinery, equipment or hazardous material when the accident occurred?

  No

  Yes

• What do you believe caused the accident?

• Any knowledge of prior problems, injury(s) or claims?

  No

  Yes

• Any other witness(s)?

Other possible witness(s)

• Witness name

• Any comment(s) made by injured employee?

  No

  Yes

• Have you talked to the injured employee since the accident? If so, what did they say?

  No

  Yes

• Was the injured employee following safety procedures concerning this task?

  No

  Yes

• Was a JSA completed and reviewed with the injured employee for this specific task?

  No

  Yes

• Signature of Witness

  Sign

Sign Off

• Form completed by

  Sign

• Select date

  Date

• Job Superintendent Signature

  Sign

• Select date

  Date

• Safety Director

  Sign

• Select date

  Date