Witness Statement

Incident Details

Incident *

Incident Date *

Location *

Interview? *

Yes

Date of Interview *

Witness / Involved Persons Details

Name *

Date of Birth *

Position *

Telephone *

Statement

Please provide a detailed description of the incident / event in your own words. You may draw pictures or diagrams to help explain the incident. *

Event Timeline

Please summarise the incident sequence from start to finish. *

General Questions

Did you notice anything usual prior to or during the incident? (sights, sounds, smells, etc.) *

What was your role in the incident? *

What conditions may have influenced the incident? (weather, time of day, equipment etc.)

Declaration

Witness Name *

Date *

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