Preliminary Witness Statement Forms

Please complete a Preliminary Witness Statement and provide a detailed description of the incident that you observed or what was reported to you.  This should include dates, times and names.

Please note that if you remember additional information after completing this form, you should call the QA/CC Department at your earliest convenience.  All information provided is confidential and should not be shared with others.

Return the completed form to the QA/CC Department via email to qualityassurance@issny.org or by mail to Independent Support Services, Inc., ATTN: QA/CC, 380 Rabro Drive, Hauppauge NY 11788

Preliminary Witness Statement Fillable (PDF)
English, Fillable
Revised Jan. 2021

Preliminary Witness Statement Spanish (PDF)
Spanish
Revised 06/06/2404/02/26

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Created 04/02/26.