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Witness Statement Form

  1. 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.

  2. PART A: Incident Information
  3. Name of person involved:
  4. Location of incident (facility)
  5. Name of Staff member completing this form
  6. PART B: Witness Information
  7. Witness is a:*
  8. PART C: Witness Statement
  9. Witness Signature
  10. *I certify that the above information is true, correct, and complete to the best of my knowledge.
  11. 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.

  12. Leave This Blank:

  13. This field is not part of the form submission.