Witness Statement

WITNESS STATEMENT

(To Be Completed by the Witness)

"*" indicates required fields

Store Location*

Manager's Email*

Name of Injured Employee:*

First Name Last Name

Date of Injury*

Name of Witness:

First Name Last Name

Phone

Address of Witness:

Street Address Address Line 2 City State ZIP Code

Did you actually witness the accident or injury?*

Yes

If yes, please describe what you saw:*

What part of the body was injured? (head, back, neck, etc.)*

Describe the injury (strain, bruise, cut, etc.)

What did the injured employee say at the time of the accident or injury?*

Did the injured employee complain of pain? If so, where?*

Explain what the employee was doing at the time the accident or injury occurred?*

Signature of Witness*

Date*

Willfully making a false state for the purpose of obtaining or denying benefits is a crime subject to penalties of up to 10,000 per violation.