Information

  • Incident type

  • Location Statement Recorded
  • Observation Date

  • Prepared By

  • Name of Employee

  • Statement

  • Add media

Employee Signature

  • Employee

Acknowledgement made and signature witnessed by me

  • Supervisor 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.