Accident Witness Statement

*To be completed by accident witness

First Name (Witness)

Last Name (Witness)

Witness Supervisor | First Name

Witness Supervisor | Last Name

Job Title of Witness

Witness Has Been Employed at Aelieve Digital Marketing For How Long?

Home Address of Witness

City

State

Zip Code

Country

First Name (Injured Employee)

Last Name (Injured Employee)

Location of Accident

Date / Time of Accident

Describe Fully How Accident Occurred:

Describe Bodily Injury Sustained (be specific about body part(s) affected):

Recommendation On How To Prevent This Accident From Recurring:

I (the witness) affirm that this statement is true and accurate to the best of my knowledge, recollection, and understanding. I understand that I may be asked to answer further questions in person. I also understand that my statements are confidential and may only be shared with management and human resources, and may be shared with any state departments, agencies, or any other law enforcement agency having the authority to investigate the incident.