Plcb-2027-Incident Documentation Form
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1PLCB-2027 09/13
Reorder Item #4027
incident documentation form**
A L C O H O L E D U C A T I O N
Date_____________Time_________
/
am
pm
Licensed establishment name _____________________________________LID # ______________________
Patron name _________________________________________________________________________________
Address ______________________________________________________________________________________
Phone Number_______________________Employer ________________________________________________
Age of the person _______________ Verified or Approximated (circle one)
Physical Description of Patron ___________________________________________________________________
__________________________________________________________________________________________
1. Was the patron’s ID checked? Yes_____ No_____
By Whom _________________________________
Type of ID presented ______________________ Number _________________________________________
*Check method of documentation used.
931 Declaration of Age Card
Photocopy
Video
Photo
I.D. Swipe Machine
2. Time the patron arrived ____________
/
Time departed ___________
/
am
pm
am
pm
3. Where was the patron before your place? _____________________________________________________
4. Number and types of drinks served: __________________________________________________________
5. In what amount of time were the drinks served? ________________________________________________
6. Did the patron consume food while at the establishment? Describe_______________________________
7. Was the patron injured? Yes_____ No_____ Describe the injury _______________________________
Was professional attention needed? Yes_____ No_____
How did the patron contribute to the injury? ________________________________________________
8. Were law enforcement authorities called?
Yes_____ No_____
Time of the call________
/
Who made the call? _________________________________________
am
pm
Name(s) of the officer(s) responding: ______________________________________________________
9. Did the patron drive from the establishment? Yes_____ No_____
10. Auto Make____________ Model__________ Color__________ License Number ____________________
11. If the incident occurred outside, describe weather conditions: ____________________________________
12. Describe the incident, (including eyewitness accounts) _________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
employee name_________________________________ Signature____________________________________
Address ______________________________________________________ Phone _________________________
Witness #1 name _______________________________ Signature____________________________________
Address ______________________________________________________ Phone _________________________
Witness #2 name _______________________________ Signature____________________________________
Address ______________________________________________________ Phone _________________________
Signature of person completing the form_______________________________ Date _____________________
* This form is not a legal substitute for the PLCB-931 Declaration of Age Card.
** This form may be duplicated without the permission of the Pennsylvania Liquor Control Board.
*** Once completed, keep on licensed premises for two (2) years.
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