Template

Statement of Account Incident Form

by Norhairul Nizam Bin Abdul Karim, from the Community

Use this Statement of Account incident form to document near misses, accidents, and dangerous occurrences. Record personal details such as company, name, identification number, nationality, and occupation, along with the person’s involvement in the incident as injured person, witness, supervisor, coworker, or other. Capture a detailed statement of account, interviewer and translator details, and a declaration that the statement is true. This template helps standardize evidence collection and supports safety investigations and corrective actions on site.

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

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Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
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This incident witness statement form template provides a structured format for documenting workplace incidents and accidents. The form includes essential sections for recording incident details, witness information, safety compliance checks, and detailed observations. It captures crucial information such as the date and time of the incident, location details, witness credentials, and specific observations about safety practices and personal protective equipment usage. The template also includes sections for describing the task being performed, how the incident occurred, and any resulting injuries. Complete with signature fields for both witness and supervisor verification, this form ensures thorough documentation of workplace incidents for safety compliance and record-keeping purposes.
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Use this employee and witness statement form to document workplace incidents clearly and consistently. Capture essential information including the employee or witness name, date and time, phone number, signature, and a detailed narrative of what occurred. This template supports thorough investigations, helps preserve accurate accounts, and promotes safety and compliance across job sites and workplaces. Adapt the fields to suit your procedures and store completed statements alongside other incident records for easy reference.
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Statement of Account Incident Form

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