NYC-WTC_000233682

NYC 9/11 Public Portal Document

RESPONSE GUIDELINES

2.5 Witness Account Report Form

INSTRUCTIONS The purpose of this form is to document the observations of a witness to activities that might be considered an incident warning. The individuai interviewing the witness, or potentiaily the witness, should complete this form. This may be the WUEFIM or an individual designated by incident command to perform the interview. If law enforcement is conducting the interview (which may often be the case), then this form may serve as a prompt for “utility relevant information” that should be pursued during the interview. This form is intended to consolidate the details of the witness account that may be relevant to the threat evaluation process. This form should be completed for each witness that is interviewed.

BASIC INFORMATION Date/Time of interview:

Name of person interviewing the witness:

Witness contact information Full Name: Address: Day-time phone: Evening phone: E-mail address:

Reason the witness was in the vicinity of the suspicious activity:

WITNESS ACCOUNT Date/Time of activity:

Location of activity: Site Name:

Type of facility □ Source water □ Treatment plant □ Pumpstation □ Ground storage tank □ Elevated storage tank □ Finished water reservoir □ Distribution main □ Hydrant □ Service connection □ Other

Address:

Additional Site Information:

15 Interim Final - August 2004

CITY_21MC100_004992354

NYC-WTC_000233697