W ITNESS REPORT COMPLETE AND SUBMIT THIS REPORT WITHIN

w itness report complete and submit this report within 24 hours of receipt to:   1. name of injured employee: ________________________

W ITNESS REPORT
COMPLETE AND SUBMIT THIS REPORT WITHIN 24 HOURS OF RECEIPT TO:  
1. Name of injured employee: _________________________ 2. Date of
injury: _______________
3. Time of injury: __________ 4. Department:
__________________________________________
5. Location where injury occurred:
___________________________________________________
6. Describe fully, in your own words, how the injury occurred – Be
specific: _________________
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8. Print name and title of person completing this report:
_________________________________
9. Tel. no.: ___________ 10. Your Work Address:
______________________________________
11. Your working relationship to employee:
____________________________________________
Signature: _______________________________________
Date Witness Report Submitted: _____________
4/6/2021