Incident Report

Incident Report
Store Number
Employee Name (name of person filing Incident Report):

First NameLast Name
Employee Position Title
Position title of the person filing report
If "Other" please specify:
Position title of the person filing report
Store Manager E-Mail

Confirmation EmailThis is for communication purposes between home office personnel and store management.
Incident Type

Other
Location of Incident
AREA OF STORE BOX WAS FOUND
The exact time of Incident was Date Exact Time* .
Incident occurred on Date betweenStart Time and End Time
Persons affected by Incident (choose all that apply):

Other
Were the Police notified?
Name of responding Police Officer

First NameLast Name
Phone Number of responding Police Officer

Area CodePhone Number
Police Report/Case Number (If applicable)
Is Security Footage being requested by the responding Officer(s)?
Email of responding Police Officer (required if footage is being requested)
example@example.com
NOTICE:

The Operations Department will reach out to I.T. for security footage. Do not submit any requests to I.T. separately for the footage. The Operations Department will communicate directly with the responding officer(s) to the incident and will provide security footage to them if requested to do so.
Name of Injured Person

First NameLast Name
Address of Injured Person

Street Address

Apartment/Suite/Unit

CityState

Zip Code
Phone Number of Injured person

Area CodePhone Number
What was the injured person doing at time of Incident?
Description of injuries:
Provide as much detail as possible. Cut, bruise, burn, etc.
Was medical treatment sought after by the affected persons?
Was more than one person injured?
Name of Injured Person

First NameLast Name
Address of Injured Person

Street Address

Apartment/Suite/Unit

CityState

Zip Code
Phone Number of Injured person

Area CodePhone Number
What was the injured person doing at time of incident?
Description of injuries:
Provide as much detail as possible. Cut, bruise, burn, etc.
Was medical treatment sought after by the affected persons?
Information about the Incident

Enter the details of the incident accurately.
Who was present during the Incident?
List first and last names of all employees present and within the building during incident, whether on the clock or not.
Description of Incident
Include description(s) of all involved parties, full names, description(s) of vehicles (if applicable)
Known Theft Information

If product was taken, fill out the information below for all known SKU's/quantities.

For quicker response time, please enter these items into PIP for removal.

For Product Description, please be detailed if you are not sure what specifically was taken. For example: "We Vibe product" or "Wand in long white/orange packaging".
Have inventory adjustments been entered in PIP?
Product Loss Information
Product Loss Information
Product Loss Information
Product Loss Information
Product Loss Information
Product Loss Information
Description of Injury/Injuries
Include area of body affected.
Was medical treatment sought after by the affected persons?
Did the employee use their Preferred Medical Provider?
Phone Number of Manager on Duty:

Area CodePhone Number
Signature of Person filing Report
Today's Date

MonthDayYear
Should be Empty:

Incident Report

Information about the Incident

Known Theft Information