TF SAFE CMMS - Employee Statement of Incident

Employee Name:*

Employee Team #:

Employee Title:

Date of Incident:*

Date Incident Reported:*

Site (if applicable):

Description of Incident (What happened?):*

Incident Witnesses:

Yes, there were witnesses

Witness Name(s) & Telephone Number(s):

Cause of Incident (What caused it to happen?):

How could this incident have been prevented?

Additional Statement (if needed):

I certify that I have read the above information and that it is a true, accurate, and factual statement.

Employee Signature:*

Print Witness Name:

Witness Signature:

Employee's Statement of Incident