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  • (KPKL HSE FM 05) Witness Statement

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    maxwell odhiambo
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    This witness statement form collects information about a witness to a workplace accident or incident, including their name and contact details, the date and time of the event, the name of any injured worker, the location of the event, and the witness's account of what happened. The witness must sign and date the completed statement. Additional pages may be attached if more space is needed to provide details.

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    [KPKL HSE FM 05] Witness Statement

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    This witness statement form collects information about a witness to a workplace accident or incident, including their name and contact details, the date and time of the event, the name of any injured worker, the location of the event, and the witness's account of what happened. The witness must sign and date the completed statement. Additional pages may be attached if more space is needed to provide details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    19 views1 page

    (KPKL HSE FM 05) Witness Statement

    Uploaded by

    maxwell odhiambo
    This witness statement form collects information about a witness to a workplace accident or incident, including their name and contact details, the date and time of the event, the name of any injured worker, the location of the event, and the witness's account of what happened. The witness must sign and date the completed statement. Additional pages may be attached if more space is needed to provide details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    WITNESS STATEMENT KPKL-HSE-FM-05

    WITNESS STATEMENT (Include for each witness when submitting IIR)

    Name of Witness:
    ______________________________________________________________________________

    Contact Information - Telephone and Email address:

    ______________________________________________________________________________

    Date of Accident / Incident


    ______________________________________________________________________________

    Time of Accident/Incident:
    ______________________________________________________________________________
    Injured Worker’s Name:
    ______________________________________________________________________________

    Location of Accident/Incident:
    ______________________________________________________________________________
    Your Account of the Accident/Incident/Damages:
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    Signature of Witness: _____________________________ Date: _____________________

    Note: In case of additional information you can use the plain additional page behind

    HSE DEPARTMENT
    Date of Issue: 1st November 2021
    Revision No: 01
    Page 1 of 1

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