Alcohol Incident Report Log

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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