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Accident Investigation - Witness Statement Template

This document provides a template for collecting witness statements during an accident investigation. The template includes sections for the witness's name, job title, and details about the accident such as date, time, and location. It also includes a list of questions for the witness to describe what they saw, what led up to the accident, any equipment involved, the environment, and whether other witnesses were present. The goal is to gather accurate accounts that can help determine the cause of the accident.

Uploaded by

Lina Angulo
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456 views

Accident Investigation - Witness Statement Template

This document provides a template for collecting witness statements during an accident investigation. The template includes sections for the witness's name, job title, and details about the accident such as date, time, and location. It also includes a list of questions for the witness to describe what they saw, what led up to the accident, any equipment involved, the environment, and whether other witnesses were present. The goal is to gather accurate accounts that can help determine the cause of the accident.

Uploaded by

Lina Angulo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Accident Investigation

Witness Statement
This template is designed as an example for what a good accident investigation witness statement should include
and is not indicative of what may be required in all workplaces.

We recommend that you review this template prior to its use and add any specific, relevant questions you may
have prior to your investigation.

WITNESS NAME:

JOB TITLE:

TIME OF
DATE OF ACCIDENT:
ACCIDENT:
LOCATION OF
ACCIDENT:

DID YOU DIRECTLY WITNESS THE ACCIDENT: Yes No

Thank you for assisting us in the accident investigation, your feedback is important to us! Please be as
open and honest in your recollection of the sequence of events as you remember them.

1. Can you please tell me in your own words what you saw?

2. What were you doing at the time leading up to the accident?

0345 844 4848 citation.co.uk VERSION 1 – July 2022 - 20220704-AH- MJB


Accident Investigation
Witness Statement

3. What were you doing when the accident occurred?

4. Was any equipment involved in the accident? If so, what?

5. If you were assisting the injured person at the time of the accident had you been given specific
instructions for the task being performed? If applicable, had you been trained in the task/use of the
equipment being used?

6. Did the actions of any other surrounding person contribute to the accident? E.g. pushing or striking

0345 844 4848 citation.co.uk VERSION 1 – July 2022 - 20220704-AH- MJB


Accident Investigation
Witness Statement
the other person? Describe them below:

7. What was the environment like during the time of the accident? Was it cold, hot, wet, uneven surfaces,
etc? If the accident happened outdoors what was the weather like at the time? E.g. windy, bright, etc.

8. Are you aware of anybody else witnessing the accident? If so who?

9. Do you have anything else to add to this statement you feel may be relevant to this accident? E.g. was
anything said before or after the accident that may be useful?

0345 844 4848 citation.co.uk VERSION 1 – July 2022 - 20220704-AH- MJB


Accident Investigation
Witness Statement

11. Additional comments

Witness Declaration:

I CONFIRM THAT THIS STATEMENT IS TRUE AND ACCURATE TO THE BEST OF MY RECOLLECTION.

Name: Sign:

Date:

0345 844 4848 citation.co.uk VERSION 1 – July 2022 - 20220704-AH- MJB

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