SMI INCIDENT WITNESS STATEMENT

• Document No.

• Report Title

• Job Site

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION

• DATE AND TIME OF INCIDENT

  Date

• DATE AND TIME INCIDENT WAS REPORTED

  Date

• JOBSITE

• LOCATION
  Address

• WITNESS NAME | TITLE

INCIDENT OBSERVATIONS

• WHAT DID YOU DO DURING/AFTER THE INCIDENT OCCURRED?

• WERE ALL SAFETY PRACTICES AND RULES BEING FOLLOWED?

  YES

  NO

• WAS ALL REQUIRED PERSONAL PROTECTION EQUIPMENT BEING USED?

  YES

  NO

• WERE ALL NECESSARY SAFETY DEVICES AND PROTECTIVE SYSTEMS BEING USED?

  YES

  NO

• IF YOU ANSWERED NO TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN.

• DESCRIBE TASK YOU WERE DOING WHEN INCIDENT OCCURRED?

• BASED ON YOUR OBSERVATIONS, HOW DID THE INCIDENT OCCUR?

• BASED ON YOUR OBSERVATIONS, HOW DID THE INJURY OCCUR? (IF APPLICABLE)

CERTIFY

• WITNESS SIGNATURE

  Sign

• SUPERVISOR SIGNATURE

  Sign