Establishment Information
Report Prepared By
Corporate Name
Doing Business As
Date of Incident
Time of Incident
Location of Incident
Coat Check
Dance Floor
Bar
Outside
Restroom
Other
Patrons Involved or Witnessing Incident
Person #1
Name
ID Source
Gender
Date of Birth
Role
Victim
Aggressor
Witness
Race
Height
Weight
Eye Color
Hair Color
Contact
Home Phone
Cell Phone
Business Phone
Fax Number
Email Address
Address
Address
Apt
City
State
Zip
Identification Information
Describe Vehicle
License Plate / Taxi Medallion
Distinguishing Marks
Was Patron Asked To Leave Premises?
Yes
No
Patron Escorted Off Premises?
Yes
No
If Escorted Off, How?
Did Patron Resist?
Yes
No
N/A
If Resist, How?
Was Intoxication Noticeable?
Yes
No
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Police Information
Were Police Called?
Yes
No
Responding Officer
Officer's Shield Number
Visible Injuries to Patron(s)
Complaint Report
Yes
No
Complaint Number
SPRINT Number
Were Medical Services Offered?
Yes
No
Were Medical Services Refused?
Yes
No
Did EMS/Ambulance Service Respond?
Yes
No
Patrons Removed?
Yes
No
Employee Information
Employees Involved in Incident
Name
Home Phone
Cell Phone
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Employees Witnissing Incident
Name
Home Phone
Cell Phone
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Incident Information
Video Surveillance of Premises?
Yes
No
Was Incident Captured on Video?
Yes
No
Was ID Scanned Upon Entry?
Yes
No
If Not, Was Record Made of ID?
Yes
No
Was Any Physical Evidence Recovered?
Yes
No
If Yes, Describe Evidence
Describe Incident