Accident Witness Statement
University of Maryland Baltimore County
(to be completed within 24 hours of the accident)
Injury Information
Injured Employee First Name
Injured Employee Last Name
Department
Job Title
Did you witness the accident??
Yes
No
Location
Bldg. and Area (hall way, office, etc)
Date of Accident
MM/DD/YYYY format
Time of Accident
hh:mm AM/PM format
Accident Details
describe the work-process you were engaged in, give the purpose of the function or task, describe how the injury occured, and explain the cause
Part of Body Injured
be specific - example: right middle finger, left ankle, upper back
Was safety equipment provided?
Yes
No
Was safety equipment used?
Yes
No
If no, explain
.
Recommendation on how to prevent this accident from recurring
Witness Name
Witness Work Phone
Witness Email
By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge