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State of California

Department of Alcoholic Beverage Control

INCIDENT LOG

Instructions: Complete an Incident Log for each patron involved. If you see a drunk driver, call 1-800-TELL-CHP PATRON INFORMATION

INCIDENT DATE

INCIDENT TIME

1. PATRON'S NAME (First, middle, last)

PATRON'S PHONE NUMBER

ADDRESS

(Street number and name, city, state, zip code)

PATRON'S EMPLOYER

2. PATRON WAS INJURED

IF YES, ON WHAT PART OF BODY MEDICAL ATTENTION WAS GIVEN HOSPITALIZATION REQUIRED

YES

NO

3. PATRON WAS A MINOR

YES

NO

IDENTIFICATION WAS CHECKED

YES

NO

YES NO YES DESCRIPTION OF IDENTIFICATION SHOWN

NO

4. WHERE WAS PATRON BEFORE YOUR PLACE

5. HOW DID PATRON CONTRIBUTE TO HIS/HER INJURY

EMPLOYEE INFORMATION

6. EMPLOYEE'S NAME

(First, middle, last)

EMPLOYEE'S PHONE NUMBER

ADDRESS

(Street number and name, city, state, zip code)

7. EMPLOYEE'S NAME

(First, middle, last)

EMPLOYEE'S PHONE NUMBER

ADDRESS

(Street number and name, city, state, zip code)

INCIDENT INFORMATION

8. ALCOHOLIC BEVERAGE RELATED INCIDENT

9. DRINK(S) SERVED (Number and type)

YES

NO

10. POLICE WERE NOTIFIED

IF YES, BY WHOM

WHAT POLICE AGENCY

DATE OF CALL

TIME OF CALL

YES NO 11. HOW WAS INCIDENT BROUGHT TO YOUR ATTENTION

12. DESCRIBE INCIDENT (Including action you took to prevent or control the incident)

Continued on reverse

WITNESS INFORMATION

  • 13.

    WITNESS' NAME(First, middle, last) ADDRESS (Street number and name, city, state, zip code)

  • 14.

    WITNESS' NAME(First, middle, last) ADDRESS (Street number and name, city, state, zip code)

WITNESS' PHONE NUMBER

WITNESS' EMPLOYER

WITNESS' PHONE NUMBER

WITNESS' EMPLOYER

15. SIGNATURE OF PERSON MAKING REPORT

PERSON'S TITLE

REPORT DATE

X

ABC-607 (11/00)

Illustration No. 1

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