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.
Known Theft/ShopliftingEmpty Product Box FoundInjuryPower Outage/Non-Emergency
Location of Incident*
YESNO
The exact time of Incident was Date Exact Time* .
Approximate time of Incident occurred Date betweenStart Time and End Time on Date of Incident*
Employee(s)Customer(s)Maintenance Technician (Non-Fascinations employee)Other
YesNo
Name of responding Police Officer*

First NameLast Name
Phone Number of responding Police Officer

Area CodePhone Number
Police Report/Case Number (If applicable)
YesNo
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.
YESNOUNKNOWN
YesNo
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.
YESNOUNKNOWN
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".
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.
YesNo
YesNoNot Sure
Phone Number of Manager on Duty:

Area CodePhone Number
Signature of Person filing Report*

Clear
Today's Date*

MonthDayYear
Should be Empty:

Incident Report

Information about the Incident

Known Theft Information