"Alcohol Incident Report Form - Topshelf"

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ALCOHOL INCIDENT REPORT
ALL employees and customers involved or witnessing the incident need to fill out a separate report and
document in their own words what they saw and what happened.
Attach a copy of guest check to the report made by the specific server or bartender involved.
Guest’s name: _______________________________________________ (If possible)
Your name: __________________________________
Contact Info _____________________
You are an (circle one)
Employee
Customer
Date of incident:_____/_____/_____
Time of incident:______ am / pm
Type of incident (Check one)
Refused Alcohol Service based on:
Apparent intoxication/physical impairment. What signs made you come to this conclusion? Ex. slurring,
change in behavior, loss of balance, aggressive, etc.
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Was this person served alcohol by you or in the establishment? YES
NO
If the answer is yes:
How many drinks were served? ____________ Over what period of time? _______________
What type of drinks were served? __________________________________________________
Was food offered or served to this person? YES
NO
If the answer is yes:
What time was the food offered/served? ____________
What food was served? _____________________________________________________________
Person was providing alcohol to a minor
Was the minor able to consume any alcohol?
If so, how much do you think they were provided ________________________________________________
Provided alternate transportation (Yes / No) If yes, complete one of the following
ALCOHOL INCIDENT REPORT
ALL employees and customers involved or witnessing the incident need to fill out a separate report and
document in their own words what they saw and what happened.
Attach a copy of guest check to the report made by the specific server or bartender involved.
Guest’s name: _______________________________________________ (If possible)
Your name: __________________________________
Contact Info _____________________
You are an (circle one)
Employee
Customer
Date of incident:_____/_____/_____
Time of incident:______ am / pm
Type of incident (Check one)
Refused Alcohol Service based on:
Apparent intoxication/physical impairment. What signs made you come to this conclusion? Ex. slurring,
change in behavior, loss of balance, aggressive, etc.
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Was this person served alcohol by you or in the establishment? YES
NO
If the answer is yes:
How many drinks were served? ____________ Over what period of time? _______________
What type of drinks were served? __________________________________________________
Was food offered or served to this person? YES
NO
If the answer is yes:
What time was the food offered/served? ____________
What food was served? _____________________________________________________________
Person was providing alcohol to a minor
Was the minor able to consume any alcohol?
If so, how much do you think they were provided ________________________________________________
Provided alternate transportation (Yes / No) If yes, complete one of the following
Friend - Name _____________________________ Contact numer( _ _ _) _ _ _-_ _ _ _
Car Make and Model _________________________ Tag # ________________
Taxi - Driver’s Name _____________________________ ID Number __________________
Cab Company _________________________ Phone ( _ _ _) _ _ _-_ _ _ _
Uber, etc - Driver’s Name _____________________________ Tag # _______________
Phone ( _ _ _) _ _ _-_ _ _ _
Other - ____________________________________________________________________
___________________________________________________________________________
Altercations or other problems
Was anyone injured?
Yes
No
Was an ambulance called?
Yes
No
If yes to either question, provide details as you know them. _____________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Had to call 911 or the police
Yes
No
If yes, what time were they called? ______________ What time did they arrive: ______________
What was the result of the call? _______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name(s) of person(s) involved in incident if they are not filling out a report and contact information (if possible).
Name
Contact info
_____________________________________________
____________________________
_____________________________________________
____________________________
_____________________________________________
____________________________
Signature ___________________________________
Today’s Date: _____/_____/_____
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