Free Witness Statement - Washington

Department of Labor and Industries Division of Occupational Safety and Health PO Box 44600 Olympia WA 98504-4600 Witness name Victim's name Job title Job title

WITNESS STATEMENT
Inspection No. Employer Employer Inspector ID

Accident date

Time of accident

Nature of occurrence

I (was, was not) in the near vicinity of the accident when it happened. If near vicinity, list names of those persons you actually saw in the vicinity at the time of the occurrence.

If you were not in the area when the accident occurred, but in another pertinent area, please give your location and the names of the persons you saw, or believe were present, in your area.

I (am, am not) a supervisor of the injured employee. Give a factual statement of your actions and observations, preceding, during and following the occurrence (beginning with the condition of the equipment, or operations being performed, when you came to work, etc.):

Why do you think the occurrence happened?

F416-093-000 witness statement 10-06

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WITNESS STATEMENT (continued)

How do you think it can be prevented in the future?

Additional space for comments

Names of others with knowledge of the occurrence 1)

3)

2)

4)

I request my identity not be disclosed. My identity may be disclosed upon request. I understand that, if I request confidentiality, my identity will be held in confidence until such time as I may be called to testify in a court proceeding, at which time it may be produced upon demand of opposing counsel. Additionally, this entire statement may be made available to other agencies if it will assist them in the performance of their statutory functions. This statement may be subject to disclosure only in accordance with applicable statutes such as WISHA, the Washington Public Disclosure Act and agency policy. I also understand that RCW 49.17.160 of the Washington Industrial Safety and Health Act (WISHA) prohibits my employer from discriminating against me in any way because I have voluntarily furnished this information to the Department of labor and Industries. If such discrimination or retaliation by my employer occurs as a result of my making a statement, I may file a WISHA discrimination complaint with the department. I declare under penalty of perjury of the laws of the state of Washington that the foregoing is true and correct. I also understand that I may be criminally prosecuted pursuant to RCW 49.17.190 (2) for false statements.
Date Name (printed) Signature

Address, City State and ZIP where signed Home address Signature witnessed by: Date Name (printed) Title Signature City State ZIP Phone ( )

F416-093-000 witness statement 10-06

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