<title>2026-05-09_Mission_Senior_Secondary_Schoo

WORKER/WITNESS STATEMENT

OHS PROGRAM – INCIDENT INVESTIGATION

FORM #WS-01 | REV. 01

This statement is part of — Accident report Environmental report Near Miss N/A

WITNESS / CONTACT INFO

Witness/Worker Name

Date

Witness/Worker Address

Witness/Worker Phone #

Supervisor Name

Supervisor Phone #

Company Name

Project Name & Address

OTHER WORKERS INVOLVED

Worker #1

Worker #2

Worker #3

INVESTIGATOR

Investigator Name

Investigator Phone

STATEMENT

REVIEW & SIGN-OFF

WITNESS / WORKER

Name

Date

SIGNATURE

INVESTIGATOR

Name

Date

SIGNATURE