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ApplyStatement Date: [Date]
1.1 Full Name: [First Name Last Name]
1.2 Job Title/Department: [Title/Department]
1.3 Work Location: [Office/site]
1.4 Phone/Email: [Contact info]
1.5 Supervisor (Optional): [Name]
2.1 Date of Incident: [MM/DD/YYYY]
2.2 Time of Incident: [Time]
2.3 Location: [Specific location]
2.4 Type of Incident: ☐ Safety ☐ Harassment ☐ Misconduct ☐ Theft ☐ Discrimination ☐ Other: [Type]
2.5 People Involved: [Names and roles, if known]
2.6 Other Witnesses (If Known): [Names]
3.1 Where I Was and What I Was Doing. [Describe your position and activity before the incident.]
3.2 What I Saw and Heard. [Chronological description. Include exact words if you remember.]
3.3 What Happened Next. [Steps that followed, actions taken, who responded.]
3.4 Injuries or Property Damage (If Any). [Describe what you observed.]
3.5 Security Cameras / Evidence (If Known). [Camera locations, photos, messages, etc.]
4.1 Immediate Actions. [Who you told, reports made, assistance provided.]
4.2 Reports/Notifications. I reported this to: [HR/Manager/Security] on [Date/time].
5.1 Attached items (if any):
Exhibit A: [Photo/video]
Exhibit B: [Email/text message]
Exhibit C: [Other]
Exhibit A: [Photo/video]
Exhibit B: [Email/text message]
Exhibit C: [Other]
6.1 I understand this statement may be used for an internal investigation and may be shared with those who need to review it.
6.2 I have written the above to the best of my knowledge and based on what I personally observed.
Employee/Witness: [Full Name]
Date: [Date]
Signature: ___________________________
Subscribed and sworn (or affirmed) before me on [Date], by [Employee/Witness Name], who is personally known to me or has produced identification.
Notary Public Signature: _______________________
My Commission Expires: _______________________
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For quick answers, scroll below to see the FAQ.
Frequently asked
An Employee Witness Statement is a written account from an employee describing what they personally saw, heard, or experienced during a workplace incident. It is often used for internal investigations, HR processes, safety reports, or legal claims. The goal is to capture facts in a clear, chronological format.
Include: the incident date/time/location, people involved, what you personally observed (not rumors), exact words if remembered, actions taken, and any supporting evidence. Keep the statement factual and avoid speculation.
Usually no for internal HR investigations, but it can be requested in some legal contexts. This template includes an optional declaration section and an optional notarization section only if needed.
It’s best to focus on facts. If you include opinions, clearly label them as your impression and explain what observations caused that impression. This template is structured to prioritize objective facts.
Typically HR, management, and investigators may review it, and it may be shared with legal counsel or a government agency if the matter escalates. This template includes a confidentiality reminder, but actual confidentiality depends on law and company policy.
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