Employee Witness Statement Template

Statement Date: [Date]

1. Employee (Witness) Information

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. Incident Information

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. What I Observed (Facts Only)

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. Actions I Took

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. Attachments (Optional)

5.1 Attached items (if any):

• Exhibit A: [Photo/video]

• Exhibit B: [Email/text message]

• Exhibit C: [Other]

6. Confidentiality and Accuracy

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.

Signatures

Employee/Witness: [Full Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (Optional)

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: _______________________