Alcohol Incident Report printable pdf download

ALCOHOL INCIDENT REPORT

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