Written statement template
An employee written statement for an incident, mistake or complaint: what happened, when, who was involved and what you propose.
- ๐บ๐ธ US format ยท Letter size
- Free
This is a sample form. Check that the terms and pay match federal and state labor rules and your company policy.
Fill in what you need. The preview updates as you type.
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A general template, not legal advice
This is a general template. Laws and company policies differ by state and employer, so check anything with legal or tax consequences with a professional before you rely on it.
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Written Statement
| Employee | Jordan Lee |
|---|---|
| Title | Customer Support Specialist, Support |
| To | Taylor Kim, Support Manager |
| Date of statement | October 8, 2026 |
| Date of event | October 6, 2026, About 2:30 pm |
| Location | Support floor, 3rd floor, Austin office |
| Others present | Shift lead, building security officer |
Statement of events
At about 2:30 pm on October 6, I was on a call with a customer when the power went out on the support floor and the ticketing system closed. The call dropped.
At 2:35 pm I notified the shift lead and called building security, who checked the electrical panel. Power came back at 2:50 pm.
After the system restarted, two tickets I had been working on had not saved. I called both customers back, confirmed the details and re-entered the tickets by 3:30 pm.
Current status
The system and power are working normally. Both tickets were re-entered the same day and the customers were told what happened.
What I have done or propose
I have asked Facilities to inspect the panel. I also turned on the five-minute autosave setting in the ticketing system and suggest the whole team do the same.
I confirm that the statement above is true and accurate to the best of my knowledge.
October 8, 2026
Employee signature: Jordan Lee
Received by: ______________________
How to use it
A written statement is your account of what happened, in your own words, for your manager or HR. Fill in the header, then write the statement in time order: what happened, at what time, who you told and what you did next. A blank line starts a new paragraph. Current status and what you propose are optional, but a line on each helps the reader decide what to do next.
Print it or save the PDF, sign it, and keep a copy for yourself. The received-by line is for whoever takes the statement.
Things to watch
Stick to what you saw and did. Leave out guesses about other people's motives and refer to others by role where you can. The closing line only confirms that the statement is accurate; do not add sentences that accept blame or give up any rights. If the statement is part of a disciplinary process or a complaint, you can ask HR what happens next before you sign, and you can talk to an employment lawyer if the stakes are high.
Calculators that go with this
Frequently asked questions
Is this the same as an incident report?
An incident report is a company form, often filled in by a supervisor, with fixed fields. A written statement is one person's account in their own words. You may be asked for both after the same event.
Do I have to sign it?
Most employers ask for a signed statement. Read it once more before signing and keep a copy. If something is wrong, correct it before you sign rather than after.
Can I use it for a complaint about a coworker or manager?
Yes. Describe the events the same way, in time order with dates, and send it to HR. For harassment or discrimination complaints, your handbook names where to report; follow that so the complaint is on record.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.