When to Use a Witness Incident Report
- Police investigations and court proceedings
- Employment disputes (e.g., discrimination, harassment)
- Car accidents
- Insurance claims
- Student incidents (e.g., fights, bullying, threats)
Sample
Full Name: [WITNESS NAME] Title/Role: [TITLE / ROLE] Address: [WITNESS ADDRESS]
Phone: [PHONE] E-Mail: [E-MAIL]
Signature: Date: [MM/DD/YYYY]
INCIDENT DETAILS
Date of Incident: [MM/DD/YYYY] Time: [TIME] ☐ AM ☐ PM
Location: [INCIDENT LOCATION]
Conditions That Influenced the Incident (e.g., weather, terrain): [CONDITIONS]
Describe the Incident: [DESCRIBE INCIDENT]
Any photographs, video recordings, or other evidence of the incident should be provided to the recipient at the time this report is filed.
INJURIES
Was anyone injured? ☐ Yes ☐ No
If yes, describe the injuries: [DESCRIBE INJURIES]
PROPERTY DAMAGE
Was there apparent property damage? ☐ Yes ☐ No
If yes, describe the damages: [DESCRIBE DAMAGES]
OTHER WITNESSES
Were any other witnesses present? ☐ Yes ☐ No
If yes, enter the witnesses’ names and contact info:
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
POLICE / MEDICAL SERVICES
Police Notified? ☐ Yes ☐ No | If yes, was a report filed? ☐ Yes ☐ No
Was medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [SPECIFY]