Witness Report Form

Date of Report

Is Witness filling out this form or someone on their behalf?

Witness is filling out form.

Another person if filling out form for the witness.

Facility/Area Name

Name of Person Filling Out Form if NOT Witness

First Name

Last Name

Witness Name

First Name

Last Name

Address

City

State

Zip

Witness Phone

Is the witness a minor?

Yes

No

If yes, list parent/guardian.

Date of Incident

Time of Incident

Location of Incident

What were you doing when the incident occurred?

What did you do after the incident occurred?

Describe what you saw that caused or contributed to the incident?

I certify that statement is true and accurate to the best of my recollection.

I Agree

Signature of Witness

Put emails here for anyone who needs a copy of this report.

Email