Injury Witness Statement Template
[Organization / Employer / School / Program Name, if applicable]
[Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]
1. Witness Information
Witness Full Name: [First, Middle, Last]
Date of Birth (optional): [MM/DD/YYYY]
Home Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
Role at Time of Incident (check or describe):
Employee
Student / Child
Customer / Visitor
Driver / Passenger
Bystander
Contractor / Vendor
Other: [Describe]
2. Injured Person Information (If Known)
Full Name of Injured Person: [Name or “Unknown”]
Role (employee, student, customer, etc.): [Role or “Unknown”]
Your Relationship to Injured Person (if any): [Coworker / Friend / Family / None / Other]
3. Incident Date, Time, and Location
Incident Date: [MM/DD/YYYY]
Approximate Time: [HH:MM a.m./p.m. or “Unknown”]
Location of Incident (room, area, street, worksite, etc.): [Location]
Type of Setting (check one):
Workplace
School / Childcare
Sports / Recreation
Public place / Business
Roadway / Vehicle / DUI-Related
Home / Residential
Other: [Describe]
4. Your Position and Conditions at the Time
Where were you when the incident happened?
[Example: “Standing near the entrance,” “At my workstation five meters away,” “Driving behind the other vehicle,” “Sitting in the stands,” etc.]
Approximate distance from the incident: [e.g., “About 2–3 meters / 6–10 feet away”]
What were the general conditions?
Lighting: [Bright / Normal / Dim / Dark / Streetlights / Other]
Weather (if applicable): [Clear / Rain / Snow / Ice / Fog / Other]
Surface conditions (floor/ground): [Dry / Wet / Slippery / Uneven / Icy / Other]
5. Events Before the Incident
Describe anything you observed immediately before the injury occurred (if relevant):
What the injured person was doing:
[Free-text, e.g., “walking across the floor,” “carrying a box,” “running during the game,” “driving through the intersection.”]
Actions of other people, vehicles, or equipment you noticed:
[Free-text, e.g., “another car speeding,” “spill on the floor,” “equipment making unusual noise,” “children running in the area.”]
6. Description of the Incident (What You Saw and Heard)
Provide a clear, step-by-step description in your own words. Focus on facts, not opinions or guesses.
Incident Description:
On [Date] at approximately [Time], I was [describe what you were doing and where you were]. I saw the following:
[Free-text narrative. Suggested structure:]
[Describe the first thing you noticed, e.g., “The injured person was…”]
[Describe how the incident started, e.g., “I saw them slip on… / I saw the two vehicles collide… / I saw the equipment jam and the person’s hand caught…”]
[Describe what happened next, including any falls, impacts, sudden movements, or collisions.]
[Describe any sounds or statements you heard (screeching tires, shouting, “I’m hurt,” etc.).]
[Describe how the injured person came to rest (on the floor, against a wall, in the vehicle, etc.).]
If you did not see the entire incident from start to finish, explain which part you observed and what you did not see.
7. Injuries Observed
Describe any injuries or physical signs you personally observed on the injured person:
Body Part(s) You Noticed Were Affected:
[Example: “Right ankle,” “forehead,” “left hand,” “lower back,” etc.]
Visible Signs of Injury:
[Example: redness, swelling, bleeding, limp, difficulty moving, holding a body part, loss of balance, loss of consciousness.]
Injured Person’s Behavior or Statements:
[Example: “They said, ‘My back hurts,’” “They said they felt dizzy,” “They were crying,” “They did not respond to questions for a short time.”]
8. Actions Taken After the Incident
Describe what you did after the incident occurred:
Did you call for help? [Yes / No]
If Yes, who did you call (911, supervisor, teacher, security, other): [Describe]
Did you provide any first aid or assistance? [Yes / No]
If Yes, describe briefly (without giving medical opinions):
[Example: “I helped the person sit down,” “I brought an ice pack,” “I stayed with them until EMS arrived.”]
Did emergency services or other staff respond?
Agency / Staff: [Police / EMS / Fire / Internal first aid / HR / Other]
Approximate arrival time: [HH:MM a.m./p.m. or “Unknown”]
What happened next, to your knowledge?
[Example: “They walked away with assistance,” “They were taken by ambulance,” “They returned to class,” “They left in a private vehicle.”]
9. Other People Involved or Present
List any other people you know were present or involved (if known):
Person 1:
Name: [Name]
Role (employee, student, driver, etc.): [Role]
Involvement (witness / helped / other): [Describe]
Person 2:
Name: [Name]
Role: [Role]
Involvement: [Describe]
[Add additional names if needed, or write “Not known” if you do not know their identities.]
10. Additional Information or Clarifications
Use this section for any other details you believe are important or that may help clarify what you saw. This may include:
Anything you did not see or are unsure about.
Whether your view was blocked at any time.
Any relevant background (for example, “I noticed liquid on the floor earlier,” or “I had seen the two vehicles earlier in traffic.”)
Additional Information:
[Free-text narrative]
11. Statement of Truth and Signature
Please read before signing.
I, [Witness Full Name], declare that this Injury Witness Statement is true and accurate to the best of my knowledge and recollection. I understand that this statement may be used by the organization, insurer, or legal representatives in connection with the incident described above.
If I later remember important additional details or need to correct any part of this statement, I will inform the requesting organization as soon as I reasonably can.
Witness Signature: _______________________________
Printed Name: [Witness Full Name]
Date Signed: [MM/DD/YYYY]
Place Signed (City, State/Province): [Location]
12. For Internal / Office Use Only (Optional)
Received By (Name and Title): [Name, Title]
Date Received: [MM/DD/YYYY]
Reference / Case / Claim Number: [Number]
Notes:
[Short internal notes, if needed.]
