Witness Statement Form

This form is to document any and all information if an incident or near miss occurs while on duty or in the field for TRK Enterprises Inc. dba Pipe Pros. Every employee involved is to fill this out ASAP.

Region*
Select your location
Personal Information
Name (Employee filling out form.)*
First Last
Event Information
Customer*
Rig*
Date of event*
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
TRK/Pipe Pros Employee(s) Involved*
Where were you at the time of the incident? (Be specific as to rig floor, by the catwalk, in the truck, etc.)*
What were you doing at the time of the incident?*
What was the injured person doing at the time of the incident? (If you were the injured person, please put N/A.)*
Describe in your own words, what happened and what did you witness? (Be as detailed as possible.)
Signature
Employee Name *Signature**
Date Signed*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Witness Statement Form

Personal Information

Event Information

Signature