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PATRON INFORMATIO
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