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Site Health and Safety Plan <br />19133 East Liberty Road, Clements, California <br />August 16, 2022 <br />Page 42 <br /> <br />Sharp Environmental Technologies, Inc. <br />17. ACCIDENT WITNESS STATEMENT <br />(To be completed by accident witness) <br />Name of injured employee: <br /> Last First Middle <br />Name of witness: Phone: <br /> Last First Middle <br />Job title: SET 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 /> <br /> <br /> <br /> <br />Describe bodily injury sustained (be specific about body part[s] affected): <br /> <br /> <br /> <br />Recommendation on how to prevent this accident from recurring: <br /> <br />Name of witness’s supervisor: Phone: <br /> Last First <br />Witness signature: Date: <br />