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Injury/Illness Report <br />witness statement - To be completed by witnesses to the accident <br />(Make copies of this page as necessary.) <br />Name: <br />Address: <br />Employer: <br />Position/Craft: <br />Phone: <br />This statement is in reference to: <br />Site of accident (job name, location): <br />Date of accident: <br />Describe what you know about the accident, what you saw or heard, what you were doing before the accident, what you <br />did after the accident (Use additional pages as necessary): <br />This statement is true to the best of my knowledge and memory. <br />Signature <br />Health And Safety Program <br />Date <br />A-8 <br />19E-39