Injury Witness Form As a witness to any injury that may occur on a Tactical Construction job site, please take the time to fill out this form to further assist our Human Resources Department to better access the incident Witness Witness Name * Witness Name First First Last Last Witness Phone Number * Witness Email * What is the Inured Persons Name? * What is the Inured Persons Name? First First Last Last Date of Injury * Where did the injury happen? * Where were you/what were you doing when the injury occurred? * Describe what happened (who, what, where, when, how, etc.) * What was the cause of the incident (i.e., weather, safety protocol violation, etc.) * List all tools, equipment, machinery, materials, or chemicals in use when the injury occurred: * What personal protective equipment was the employee using/wearing at the time of injury? * Is there photo/video? * Yes No If yes, explain * Witness Photo Upload Drop a file here or click to upload Choose File Maximum upload size: 26.21MB If there were any other witnesses, please list their names here: * I agree I declare that the above statements are true and understand that it is a felony to defraud an insurer by providing a false/misleading statement. If you are human, leave this field blank. Submit
