Statement - (Forms/Publications)
Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title   Statement (108 KB PDF)

This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.

Form number F416-016-000
Online only. See document above to download.
Keywords declaration, statement, violation, witness statement
Languages English
Valid dates 10-2006
Contact information

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.