Employee witness statement form11/19/2023 This is a blank section that must have enough space for laying out the detailed statements of the witness about the incident. On the other hand, a questionnaire form can also be separately provided for the employee or the witnessed in order to gather in-depth details and include subjects that will be used for the process of investigation. How the employee knew about the incident will also be indicated along with a few questions to be answered that are associated with the incident. This contains the date and the place of the incident that was witnessed by the employee. Other details of the witness include his contact number at work and at home to allow the authority in calling the witness for further clarification of his statements and claims. This will have the name of the witness, his job position in the company, as well as his work schedule or the number of service hours that he is required to comply regularly. The employee’s identification and social security numbers may also be stated in this section depending on the type of case or incident to be reported. Below are some of the sections that should be present on the form to assure that enough data will be collected for the case: Witness Information All bills and appropriate records associated with your workers' compensation claim should be directed to the Office of Risk Management, either through mail or secure e-mail.Employee witness statement forms have simple outlines and formats as it will center on the details and description of the incident report that the employee witnessed. If you are an employee and have a workers' compensation claim with Northwestern University, please inform your medical facility that your visit is in relation to that claim and provide the claim number. Guidance for Workers' Compensation Billing Guidance for Managers and Telecommuting Employees.Evanston Workers' Compensation Brochure.Northwestern Treatment Authorization - Chicago.Supervisors Injury or Illness Investigation Report. Employees may not be entitled to Workers' Compensation benefits and can be held responsible for any expenses incurred. Northwestern University employees are advised that if these instructions are not followed, Workers' Compensation claims cannot be reviewed. Employees are responsible for ensuring the report is delivered to the Office of Risk Management as soon as possible and that his/her supervisor is notified.īoth the employee and the supervisor have a responsibility to assure that complete and accurate information is conveyed to the University’s Office of Risk Management.
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