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Witness Statement Template – Illinois
Use this template to separate roles, actions, statements, and observations while keeping supporting exhibits easy to reference.
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Witness Statement Template
This Witness Statement is made on [Date] by:
Full Name of Witness: [First Name Last Name]
Address: [Full Address]
Phone/Email: [Contact Information]
Occupation: [Job Title or N/A]
Relationship to Case/Parties: [Relationship or N/A]
1. Declaration of Truth
I, [Witness Name], make this statement to record my account of the events described below.
I declare that the facts stated in this witness statement are true to the best of my knowledge and belief.
I understand that making a false statement may result in penalties under applicable perjury laws.
2. Witness Identification
Witness Name: [Witness Name]
Preferred Contact Method: [Phone/Email]
Relationship to Incident Location (if any): [Employee/visitor/customer/neighbor/other/N/A]
3. Statement Purpose and Reference
Case/Incident Reference: [Case name/claim #/internal file #/other]
Recipient/Department: [Name/Organization/Department]
Parties/Organizations Mentioned: [Names or N/A]
4. Statement of Facts (Roles → Actions → Statements Heard → Visual Observations → Post-Event)
Roles: [Who was present and who appeared to be doing what]
Actions: [What actions I observed]
Statements Heard: [Words or substance of statements heard]
Visual Observations: [Distances, objects, positioning, notable details]
Post-Event: [What occurred immediately after and any follow-up I witnessed]
5. Supporting Evidence
Exhibit A: [Photographs/Video files and identifiers]
Exhibit B: [Incident report/medical report/other]
Exhibit C: [Additional document/other]
Additional Exhibits: [List or N/A]
6. Signatures and Certifications
Witness Signature: _______________________ Date: ___________
Printed Name: ___________________________
Interpreter Certification (optional): ________________________
Interpreter Name: ________________________ Language: __________
Signature: ______________________________ Date: ___________
Reviewed/Received By (optional): ____________________________
Role/Title: ______________________________ Date: ___________
7. Two-Step Injury Classification (Module)
Complete the injury classification table (if an injury was observed):
Category | Subtype | Severity (1–5) | Observed Limitation | Notes |
[Physical/Property/Other] | [Subtype] | [1/2/3/4/5/Unknown] | [None/Mild/Moderate/Severe/Unknown] | [Notes] |
[Physical/Property/Other] | [Subtype] | [1/2/3/4/5/Unknown] | [None/Mild/Moderate/Severe/Unknown] | [Notes] |
8. Multi-Employer/Contractor Chain (Module)
Employer (if applicable): [Name or N/A]
Site Owner/Controller (if known): [Name or Unknown]
General Contractor (if any): [Name or N/A]
Subcontractor/Vendor (if any): [Name or N/A]
9. Evidence Preservation (Module)
Photos/Video Captured By: [Name/Device]
File Names/IDs: [File names/IDs]
CCTV/Camera Identifiers (if any): [Camera ID/location/other]
Chain-of-Custody Identifier: [ID or N/A]
Storage Location: [Location or N/A]
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Learn more about
Witness Statement Template – Illinois
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Illinois Witness Statement Template FAQ
Why is the declaration placed at the beginning of this template?
Leading with the declaration frames the statement as a factual record and helps the witness stay grounded in what they personally know. It also makes it clear, from the first page, that the document is meant to be truthful and complete to the best of the witness’s ability. When a statement is used in an internal investigation or an administrative process, that framing can reduce the tendency to drift into advocacy or speculation. The remainder of the template then channels the witness into a structured fact pattern rather than open-ended storytelling.
How does the Roles–Actions–Statements–Observations–Post-Event structure help?
This structure is designed to capture different “types” of information that are often mixed together in free-form narratives. Roles clarify who seemed responsible for what, actions capture behavior, statements record what was said, and observations document visual details like distance and positioning. The post-event segment prevents the narrative from cutting off before important follow-up actions occur. Separating these categories makes it easier for reviewers to compare statements across witnesses and identify where accounts align or differ.
When should the injury classification module be completed?
Complete the module only if you personally observed an injury or a clear impact that can be described reliably. The table is meant to record the type of impact, a practical severity indicator, and any functional limitation you actually observed. If you did not see an injury, you can mark the section as “Unknown” or leave it blank. The goal is to avoid turning the statement into a medical assessment while still preserving useful observational information, such as whether someone appeared unable to stand or complained of pain.
What should a witness do if they are unsure about exact timing?
If you are unsure about timing, use approximate references that remain consistent throughout the statement. You can anchor events to objective markers like a phone call, a shift change, a delivery time, or a photo timestamp. The important part is to keep the sequence clear and avoid contradictory time claims. If you later confirm a time from an objective source, you can prepare a supplemental statement that notes the source and clarifies the updated timing. Transparency about uncertainty is usually better than confident but inaccurate precision.
How should a witness handle secondhand information?
Secondhand information should be clearly labeled as something you were told, including who told you and when, rather than being presented as direct observation. If you include it, keep it separate from your core factual account. This prevents confusion and helps reviewers weigh the information properly. If the secondhand information is important, the receiving party can obtain a separate statement from the person who directly observed it. Keeping the boundary clear protects the credibility of your statement.
Can a witness statement be used as an internal record even if no lawsuit is involved?
Yes, witness statements are often used to preserve facts in workplace investigations, property disputes, or administrative matters where no court case exists. The value is in documenting what was observed while memories are fresh and aligning that account with evidence like photos, logs, or camera footage. A consistent template also helps organizations compare incidents over time and identify patterns. If you want a clean, branded version of this format for repeated use, AI Lawyer can help you generate consistent witness statement packets for your process.
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