Incident Report Form Please Print - Kin Canada Page 2
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1
2INCIDENT REPORT FORM – Con’t –
Page 2
ACCIDENT OR INJURY
Yes
No
IF YES, PLEASE COMPLETE
What part of the body?
Did patron contribute to injury?
Medical Attention Given? Yes
No
Hospitalization Required? Yes
No
By Whom?
Name of Hospital?
Describe:
WAS ALCOHOL INVOLVED?
Yes
No
IF YES, PLEASE COMPLETE
Was Patron Alone? Yes
No
Number in Party _____ Who With _________________
Was Service Refused? Yes
No
Server Knows Patron? Yes
No
Reason: Signs of Intoxication
Signs of Impairment
Troublesome
Minor
Other
Was Patron Caught Drinking Alcohol Under Age? Yes
No
Please complete:
If Yes, Who Gave the Minor the Drink?
Was ID Checked? Yes
No
Age if Majority Yes
No
Driver’s
License
Was ID Falsified? Yes
No
Explain:
Was Patron Ejected from Premises? Yes
No
Please complete:
Time of Arrival?
AM/PM
Time of Departure?
AM/PM
Was Force Used to Remove the Patron? Yes
No
What Type?
Did Patron Suffer Any Injuries While being Ejected? Yes
No
Type:
Reason: Signs of Intoxication
False ID
Verbal Abuse
Destruction of Property
Fighting
Domestic Dispute
Drugs
Minor
Trespassing
Other:
TRANSPORTATION
Which Method Did Patron Use To Leave The Premises?
Did Patron Leave Alone
With Someone
Walking
Taxi
Car
Was Patron Driving? Yes
No
Friend from Home
Friend on Premises
Bicycle
Motorcycle
Other:
Police
Ambulance
Were Alternative Methods Offered? Yes
No
Specify:
If Patron Driving, Describe Vehicle: Make_______________________ Colour ___________
Licence No. ___________________ Province/State ____________ Other ______________
Direction Heading:
Was a Police Witness Statement Filed Out? Yes
No
Police Report No. ____________
WITNESSES
Last Name:
First Name:
Street Address:
City:
Postal Code:
Phone: (
)
Last Name:
First Name:
Street Address:
City:
Postal Code:
Phone: (
)
Other Comments or Remarks:
Signature
Print Name
Signature of Person
Position/Title
Completing Form
IF ADDITIONAL SPACE REQUIRED USE BLANK SHEETS AND ATTACH TO
REPORT.
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Parent category: Business