(SAMPLE) PERSONAL STATEMENT
Subject or Title of Event
Occurrence Report Number
In your own words, write down what happened in the event. Include any relevant information
from before the event began until after it was over. Include the following:
Facility or system conditions as you know
Your actions in response to the
them prior to the event.
What you were doing immediately prior to
Any equipment malfunctions.
Any indications that a problem existed.
Any inadequacies in the procedures,
practices, or training.
If additional sheets are used, each sheet should contain: signature, date, time, event title, and
occurrence report number.