DATJ Accident Witness Statement

• Site Conducted

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• What is the Division or Area where the incident took place?

  Select

• The Incident occurred to a staff member or equipment belonging to which department?

  Select

• Conducted on

  Date

• Prepared by

• Prepared with

Who

• Who was there? Initials Only)

• Who was injured?

• Who else witnessed the accident?

• Any other 'Who' Information?

What

• What were the persons involved doing?

• What was the sequence of events?

• Any other 'What' Information?

Where

• Where were the persons involved going?

• Where did the accident happen?

• Any other 'Where' Information?

When

• When did the incident take place?

• When did you take note of what happened?

• Any other 'When' Information?

Why

• Why did you see this?

• Why were the persons involved present?

• Any other 'Why' Information?

• This statement contains factual information regarding the accident that I witnessed.

• Witness Signature

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Additional Signatures

• Name and signature of person involved in the witness interview.

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