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