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Distribute as follows: ORIGINAL = DEPARTMENT HEAD, COPY = INDIVIDUAL * SCAN ALL DOCUMENTATION TO: [EMAIL REDACTED] * (This will route information to: County Admin, County Budget Office, County Attorney & Insurance Agent) Ver. 9/2015 Cortland County Incident/Accident Witness Statement Form 1. Involved Worker/Person Involved Person’s Name: 2. Witness Details Printed Name: Date of Birth: Address: Phone Employer’s Name: Occupation: Relationship to Involved Person: Co-Worker Family Other Specify: 3. Incident Details Date of Incident: Time of Incident: am / pm Place of Incident: Type of Injury if applicable (e.g. burn, cut, fracture, etc.): Location of Injury if applicable (e.g. right arm, lower back, etc.): Did you see what happened? YES NO If YES, please describe what you saw: If NO, how did you become aware of/involved in the incident? Were you exposed to any Blood/Body Fluid? YES NO 4. Declaration I declare that the details submitted are true and correct. Signature of Witness: Date: SIGN