INCIDENT STATEMENT FORM

INCIDENT STATEMENT FORM

TES-MS-1024

INCIDENT STATEMENT FORM

Document Number: TES-HS-1007

Revision Level: 1.0

Release Date: 11-4-2011

• Preliminary Incident Notification Form (Reference #)

• Date (MM/DD/YYYY):

  Date

• Incident Date (MM/DD/YYYY):

  Date

• Time:

  Date

• [Person giving statement]

  Witness

  Injured Person

  Supervisor

  Other

• Incident Statement (Please include all details of the incident, including sequence of events, locations, descriptions, persons involved, date, time, activity being performed, etc.)

• I ___________ hereby declare that the statement provided is true, accurate and free of bias and if proven to be false or untrue, I am willing to accept the appropriate disciplinary actions.

• Name:

• Job Designation:

• Signature:

  Sign

• Reviewed By:

• Job Designation:

• Signature:

  Sign