"Alcohol Incident Report Form"

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ALCOHOL INCIDENT REPORT
www.iSellsafe.com
Instructions: Complete an Incident Log for each patron involved. If you see a drunk
Incident Date
Incident Time
driver call authorities.
PATRON INFORMATION
NAME: (First/Middle/Last) _________________________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
EMPLOYER: _____________________________________________________________________
PATRON WAS INJURED (Yes/No): ______
IF YES, ON WHAT PART OF BODY: ______________
MEDICAL ATTENTION WAS GIVEN (Yes/No): ______
HOSPITALIZATION REQUIRED(Yes/No): ______
WHERE WAS THE PATRON BEFORE YOUR PLACE: ______________________________________
EMPLOYEE INFORMATION
EMPLOYEE #1. NAME: (First/Middle/Last) ____________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
EMPLOYEE #2. NAME: (First/Middle/Last) ____________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
INCIDENT REPORT
ALCOHOLIC BEVERAGE RELATED INCIDENT (Yes/ No): __________________________________
DRINK(S) SERVED (Number and type): _______________________________________________
POLICE WERE NOTIFIED IF YES, BY WHOM: ___________________________________________
WHAT POLICE AGENCY /DATE OF CALL/ TIME OF CALL: _________________________________
HOW WAS INCIDENT BROUGHT TO YOUR ATTENTION: _________________________________
DESCRIBE INCIDENT (Including action you took to prevent or control the incident):
WITNESS INFORMATION
WITNESS’ #1 NAME (First, Middle, Last): ____________________________________________
WITNESS' PHONE NUMBER: _______________________________________________________
ADDRESS : _____________________________________________________________________
WITNESS' EMPLOYER: ____________________________________________________________
WITNESS’ #2 NAME (First, Middle, Last): _____________________________________________
WITNESS' PHONE NUMBER: _______________________________________________________
ADDRESS: ______________________________________________________________________
WITNESS' EMPLOYER: ____________________________________________________________
X ________________________________
_____________________
___________
SIGNATURE OF PERSON MAKING REPORT
PERSON'S TITLE
REPORT DATE
ALCOHOL INCIDENT REPORT
www.iSellsafe.com
Instructions: Complete an Incident Log for each patron involved. If you see a drunk
Incident Date
Incident Time
driver call authorities.
PATRON INFORMATION
NAME: (First/Middle/Last) _________________________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
EMPLOYER: _____________________________________________________________________
PATRON WAS INJURED (Yes/No): ______
IF YES, ON WHAT PART OF BODY: ______________
MEDICAL ATTENTION WAS GIVEN (Yes/No): ______
HOSPITALIZATION REQUIRED(Yes/No): ______
WHERE WAS THE PATRON BEFORE YOUR PLACE: ______________________________________
EMPLOYEE INFORMATION
EMPLOYEE #1. NAME: (First/Middle/Last) ____________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
EMPLOYEE #2. NAME: (First/Middle/Last) ____________________________________________
PHONE NUMBER: ________________________________________________________________
ADDRESS: ______________________________________________________________________
INCIDENT REPORT
ALCOHOLIC BEVERAGE RELATED INCIDENT (Yes/ No): __________________________________
DRINK(S) SERVED (Number and type): _______________________________________________
POLICE WERE NOTIFIED IF YES, BY WHOM: ___________________________________________
WHAT POLICE AGENCY /DATE OF CALL/ TIME OF CALL: _________________________________
HOW WAS INCIDENT BROUGHT TO YOUR ATTENTION: _________________________________
DESCRIBE INCIDENT (Including action you took to prevent or control the incident):
WITNESS INFORMATION
WITNESS’ #1 NAME (First, Middle, Last): ____________________________________________
WITNESS' PHONE NUMBER: _______________________________________________________
ADDRESS : _____________________________________________________________________
WITNESS' EMPLOYER: ____________________________________________________________
WITNESS’ #2 NAME (First, Middle, Last): _____________________________________________
WITNESS' PHONE NUMBER: _______________________________________________________
ADDRESS: ______________________________________________________________________
WITNESS' EMPLOYER: ____________________________________________________________
X ________________________________
_____________________
___________
SIGNATURE OF PERSON MAKING REPORT
PERSON'S TITLE
REPORT DATE