Appendix 0 - Attachment H - Witness Statement Form.docx

EMPLOYEE STATEMENT FORM

FOR USE WITH OPERATIONAL INCIDENTS

All section of this form must be completed in full If a section does not apply, please mark N/A Any alterations or substitutions to this form are strictly prohibited

Supervisor:

Duty Tour Start Time: am pm End Time: am pm Time Performing Current Assignment: yrs mos Time of Maritime Experience: yrs mos

Vessel Involved in Incident: circle one service operating in F1 F2 F3 F4 F5 F6

At time of Incident, Vessel was: circle one Underway Moored

At time of Incident, Vessel was: circle one Revenue trip Non-Revenue trip

Location of Incident (Dock or Facility):

Location of Incident (Specific details- i.e. on stairs):

At time of Incident, was Vessel carrying Passengers?

YES NO

If Yes, approximately how many?

General Weather Conditions at Time of Incident:

STATEMENT

Please describe what you saw and heard in chronological order

Prior to starting work, did you participate in a Safety Briefing? If yes, what was the topic?

(Circle one) YES NO Topic:

What were you doing just before the incident?

What were you doing when the incident occurred?

What did you do after the incident occurred?

What PPE was used?

Where were the other members of your work group or crew at the time of the incident?

Please document any other relevant information pertaining to the incident.

If you did not witness the incident, but have knowledge of the incident, please state what you know.

I attest that the above information is true and accurate to the best of my knowledge.

Employee Signature: Date:

Manager Collecting Statement (print): Date:

Manager Collecting Statement (signature): Date:

Employee Statement Form Ver. 1 7/8/2024 image1.png