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 1. PATRON'S NAME (First, middle, last) ADDRESS (Street number and name, city, state, zip code) INCIDENT DATE INCIDENT TIME PATRON'S PHONE NUMBER PATRON'S EMPLOYER 2. PATRON WAS INJURED YES YES NO 3. PATRON WAS A MINOR NO IF YES, ON WHAT PART OF BODY MEDICAL ATTENTION WAS GIVEN HOSPITALIZATION REQUIRED YES IDENTIFICATION WAS CHECKED YES NO NO YES NO DESCRIPTION OF IDENTIFICATION SHOWN 4. WHERE WAS PATRON BEFORE YOUR PLACE 5. HOW DID PATRON CONTRIBUTE TO HIS/HER INJURY EMPLOYEE INFORMATION 6. EMPLOYEE'S NAME ADDRESS (First, middle, last) EMPLOYEE'S PHONE NUMBER (Street number and name, city, state, zip code) (First, middle, last) EMPLOYEE'S PHONE NUMBER 7. EMPLOYEE'S NAME ADDRESS (Street number and name, city, state, zip code) INCIDENT INFORMATION 8. ALCOHOLIC BEVERAGE RELATED INCIDENT YES YES NO IF YES, BY WHOM WHAT POLICE AGENCY DATE OF CALL TIME OF CALL NO 10. POLICE WERE NOTIFIED 9. DRINK(S) SERVED (Number and type) 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) American LegalNet, Inc. www.FormsWorkflow.com ABC-607 (11/00) American LegalNet, Inc. www.FormsWorkflow.com