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WITNESSS REPORT OF INJURY
El Paso Community College
P.O. Box 20500 El Paso, Texas 79998-0500
Witness Information
Witness name
Last:
First:
College employee
Visitor
Residence address:
Work location:
Home phone:
Work Phone:
Student
Other
On (date) ____________________________, at about (time) ____________ a.m./p.m. I was in or at (clearly
state your own location) ___________________________________________________________________
when an incident/accident involving (employee name) ___________________________________________ is
alleged to have occurred.
Check only one box.
I saw the accident.
The accident occurred in the following manner:
I did not see the accident.
Information given to me by (name of person) _________________________________ indicated the
incident/accident occurred as follows:
I know nothing whatsoever about the occurrence.
The afore mentioned information is true and correct to the best of my recollection.
Signature:
Date:
Sign completed form and mail (College mail OK) to the Risk Management Department at ASC-B.
Fraud occurs when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to
either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit.
Workers’ Compensation fraud can result in termination of position, fines, restitution of fraudulent monies
received, and/or state jail time.
The El Paso Community College District does not
discriminate on the basis of race, color, national origin,
religion, gender, age, or disability.