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2. Witness Statement

   Witness Statements should be completed for ALL incidents, accidents and emergencies. This form must be completed immediately after the incident or accident occurs. Please provide as much detail as possible. Attach additional pages if necessary. The Witness Statement is a Confidential report to City Attorney for defense of claims.

4. How to Report a Work-Related Injury, Illness or Exposure
   How to Report a Work-Related Injury, Illness or Exposure
5. Supervisor Accident Reporting Protocol
   Supervisor Accident Reporting Protocol
6. Staff Accident Reporting Protocol
   Staff Reporting Protocol
7. Fleet Accident Reporting Vehicle Card
   Fleet Accident Reporting Vehicle Card
9. Incident Reporting Procedures
   Incident Reporting Procedures

   Administrative Regulation No. 4.01.00X

10. Vehicle Accident Reporting Procedures
    Vehicle Accident/Reporting Procedures

    Administrative Regulation No. 4.01.00X

14. PART A: Incident Information
16. Name of person involved:
18. First Name*
19. Last Name*
21. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
23. Location of incident (facility)
25. Address*
27. City
28. State
29. Zip Code
31. Name of Staff member completing this form
33. First Name*
34. Last name*
35. Department*
    -- Select One --Community DevelopmentCity AttorneyCity ClerkCity ManagerFinanceFire DepartmentHuman ResourcesParks and RecreationPolice DepartmentPublic WorksUtilities
39. PART B: Witness Information
41. Witness is a:*

    1. Employee

    1. Volunteer

    1. Member of the Public

    1. Contractor
43. First Name*
44. Last Name*
46. Address
48. City
49. State
50. Zip
52. Driver's License # or ID #*
54. Phone #
56. Witness specific location at the time of incident:*
60. PART C: Witness Statement
62. Please describe in detail what you did or what you saw during the incident:*
66. Witness Signature
68. *I certify that the above information is true, correct, and complete to the best of my knowledge.
70. First Name*
71. Last Name*
73. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Witness Electronic Signature *
76. Date and Time
    Date and Time

    Date and Time
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field