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Accident Investigation - Witness Statement

Form 4020

1.Name
2.Position
3.Date
4.Worksite/Job Name
5.Date & Time of Accident
6.Please describe what you saw and heard in chronological order
7.What were you doing just before the incident?
8.What were you doing when the incident occurred?
9.What did you do after the incident occurred?
10.What was the condition of the tools, equipment, machinery and materials involved in the incident?
11.What was the type and condition of the Personal Protective Equipment (PPE) being used by the injured person when the incident occurred?
12.What was the instruction or training you and others received like on the task being performed when the incident occurred?  Please describe the training and instruction.
13.Who else witnessed or heard the incident?
14.How do you think we can prevent this incident in the future?
15.Are there any more details you would like to add to your statement?
16.I certify that the above answers are true and accurate to the best of my recollection.