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40 APPENDIX C: EMPLOYEE WITNESS STATEMENT Date of Event: ____________________ Time of Event: _____________________________ Employee Name: __________________ Job Title: _________________________________ Route: __________________ At or Near intersection: ________________________________ County: ______________________ Direction: _________________________________ Construction work: Yes No If yes, who was the contractor and foreman: _______________ Type of Work Being Performed: __________________________________________________ Weather Condition: ____________________________________________________________ Pavement Conditions: ___________________________________________________________ Did any MoDOT employee witness the event? Yes No If so, whom: ___________________ Did any MoDOT employee take pictures? Yes No If so, whom: ___________________ Was Traffic Control in Place? Yes No If Yes, what traffic control was in place: _______________________________________ Supervisor/Crew Leader, below provide a Detailed Diagram of the traffic control that is noted above: (use another piece of paper if necessary) N E S W
