Witness Statement Form

Company Letterhead

{{company_name}}

{{company_address}}

{{phone}}

{{email}}

{{website}}

WITNESS STATEMENT FORM

Date of Statement: {{date}}

SECTION 1: WITNESS DETAILS

Full Name: {{witness_full_name}}

Employee Number (if applicable): {{witness_employee_number}}

Department: {{witness_department}}

Contact Number: {{witness_contact_number}}

Email Address: {{witness_email_address}}

Relationship to Incident (e.g., employee, customer, bystander): {{witness_relationship}}

SECTION 2: INCIDENT DETAILS

Date of Incident: {{incident_date}}

Time of Incident: {{incident_time}}

Location of Incident: {{incident_location}}

Type of Incident (e.g., accident, theft, misconduct, dispute): {{incident_type}}

SECTION 3: STATEMENT OF FACTS (WITNESS ACCOUNT)

Please provide a clear and concise account of what you saw, heard, or experienced regarding the incident. Include all relevant details, individuals involved, and the sequence of events as accurately as possible. Use additional sheets if necessary.

{{witness_statement_account}}

SECTION 4: ADDITIONAL INFORMATION

Were there any other witnesses to the incident? If yes, please provide their names and contact details if known: {{other_witnesses_details}}

Do you have any physical evidence (e.g., photos, videos, documents) related to the incident? If yes, please describe: {{physical_evidence_description}}

Are there any other details or comments you wish to add? {{additional_comments}}

SECTION 5: DECLARATION

I, {{witness_full_name}}, declare that the information provided in this witness statement is true and accurate to the best of my knowledge and belief.

I understand that this statement may be used for internal investigation, disciplinary proceedings, or legal action.

Signature Block

Witness Signature: ___________________________

Printed Name: {{witness_full_name}}

Date: {{date}}