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TITLE Witness Statement Form PAGE 1 OF 1
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CONTROL EFFECTIVE
MLC-OP-LSQ-FM-05
NBR. DATE

Incident No: ________________

Name: Job Title: Supervisor’s Name:

Employee No.:
Incident Date: Incident Time:

1. Where were you at the time of the incident?

2. What were the working conditions (workplace and weather?)

Write down what happened, beginning with the normal job activity that led to the incident. Put the
events, as far as possible, in the order they happened. Try to indicate timing. Say where other
people were and what they did. Describe emergency response activities.

Please explain and list down the things/items that were moved or repositioned after the incident?

Who else might have useful information on the incident?

Signature/ Date: Work telephone

This report must be completed during the incident investigation process.