Witness Statement Form
Document Control Company: [COMPANY NAME] · Logo: [COMPANY LOGO] · Address: [COMPANY ADDRESS] Prepared by: [RESPONSIBLE PERSON] · Date: [DATE] · Approved by (signature): _________________
| Field | Value |
|---|---|
| Category | Incident and Near Miss Reporting |
| Recommended Industry | All |
| Document Type | Statement |
| Access Level | Starter |
| Last Reviewed | 2026-06-29 |
| Last Updated | 2026-06-29 |
How to Use This Template
Complete the fields as fully and accurately as possible at the time of the task or event. Route the completed document per your internal process and retain it with your records.
Template Body
For a witness to record what they observed, in their own words.
| Field | Entry |
|---|---|
| Witness name: | [] Contact: [] |
| Date of statement: | [DATE] |
| Incident date/time/location: | [____] |
Describe what you saw/heard, in your own words (use factual observations, not opinions):
[____]
Did you see the events leading up to it? [] Anything else relevant? []