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Witness Voluntary Statement

This document provides a form for recording witness statements related to incidents or accidents. The form includes fields to document the name, rank, contact information and signature of the witness. It also includes blank sections for the witness to provide a statement describing their account of the incident in question, with additional space provided on the back of the page. The form is to be completed by the Safety Officer and kept on file, with a copy forwarded to the company office.

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23 views

Witness Voluntary Statement

This document provides a form for recording witness statements related to incidents or accidents. The form includes fields to document the name, rank, contact information and signature of the witness. It also includes blank sections for the witness to provide a statement describing their account of the incident in question, with additional space provided on the back of the page. The form is to be completed by the Safety Officer and kept on file, with a copy forwarded to the company office.

Uploaded by

opytnymoryak
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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WITNESS VOLUNTARY STATEMENT

Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 1 of 2

Please complete one for each interviewed person and attach it in the Accident report.

Particulars of Witness
Name

Rank / Occupation :
Contact Address:

Date :

Time:

Location of interview:

Statement
In relation to the incident on board M/T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Please use the back of this page for any additional comments or statements relative to this statement.

Witness

Safety Officer

Signature

Signature

C:\FORMS\02_0013.PDF

MT LADON

WITNESS VOLUNTARY STATEMENT


Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 2 of 2

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INSTRUCTIONS :
To be filled in every time there is witness in an incident / accident situation and is willing to make a statement. To be
kept in the Safety Officer's file and a copy to be forwarded to the office.

C:\FORMS\02_0013.PDF

MT LADON

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