Title Page

  • Conducted on

  • Prepared by

  • Incident Type

  • Type of 'other'

  • Location of incident

  • Time of Incident

  • CSR Number

Details of person being interviewed.

  • Name of accused

  • Addressed of the accused

  • ID of the accused.


  • (CAUTION) I need to ask you a few questions in relation to an incident that occurred on (insert date above) regarding (Issue listed above) at (location listed above). Before I do, I must let you know that you are not obliged to say or do anything but anything you do say or do may be used as evidence. Officer to initial that the caution has been given.

  • Do you understand this caution

  • Do you require a support person, interpreter/Legal person or similar?

  • Mention of any support people / notes.

  • Question 1

  • Question 2

  • Question 3

  • Question 4

  • Question 5

  • Question 6

  • Question 7

  • Question 8

  • Question 9

  • Question 10

Signature section

  • I hereby acknowledge that this statement is true and correct and I make it in the belief that a person making a false statement in the circumstances is liable to the penalties of perjury.

Witness Section

  • Acknowledgement taken and signature witnessed by me in

  • at

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.