Accident Witness Statement
University of Maryland Baltimore County
(to be completed within 24 hours of the accident)
Injured Employee First Name
Injured Employee Last Name
Did you witness the accident??
Bldg. and Area (hall way, office, etc)
Date of Accident
Time of Accident
hh:mm AM/PM format
describe the work-process you were engaged in, give the purpose of the function or task, describe how the injury occured, and explain the cause
Part of Body Injured
be specific - example: right middle finger, left ankle, upper back
Was safety equipment provided?
Was safety equipment used?
If no, explain
Recommendation on how to prevent this accident from recurring
Witness Work Phone
By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge