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' ACCIDENT WITNESS STATEMENT <br /> (To be completed hr accident witness) <br /> ' Name of injured employee: <br /> Last First Middle <br /> ' Name of witness: Phone: <br /> Last First Middle <br /> ' Job title: AA&A employee(Y/N)since: <br /> Home address of witness: <br /> ' City: State: Zip code <br /> Accident location: <br /> Address Area(loading dock,bathroom,etc.) <br /> ' Date of accident: Time of accident: <br /> ' Describe fully how accident occurred(including events that occurred immediately before accident): <br /> ' Describe bodily injury sustained(be specific about body part[s] affected): <br /> 1 <br /> Recommendation on how to prevent this accident from recurring: <br /> ' Name of witness's supervisor: Phone: <br /> Last First <br /> Witness signature: Date: <br /> Ami Adini <br /> ' R��Assoeintes,Inc. <br />