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Employee & Customer Incident Report
Person Entering Information
*
First
Last
Store Number
*
Select Store
201
202
203
204
205
206
207
210
302
305
308
308
310
311
315
317
319
320
321
322
323
324
333
430
530
539
555
600
310
612
619
620
643
677
750
777
780
801
802
803
804
805
806
Store Hours
*
Select Option
24 HR
Limited
Weather Conditions
*
Select Option
Clear
Fog / Mist
Rain
Snow / Ice / Sleet
Store Manager
*
First
Last
District Supervisor
*
First
Last
Date of Casualty
*
Time of Casualty
*
Casualty Location
*
Select Option
Sales Counter
Sales Floor
Bank
Backroom
Auto
Cooler
Parking Lot
Incident Type
*
Select option
Robbery-Store
Robbery-Deposit
Burglary
Vandalism
Larceny
Employee #1 Name
*
Employee #1 Employee #
*
Employee #1 Date of Hire
*
Employee #1 Race
*
Employee #1 Sex
*
Employee #1 Position
*
Select Option
Team Member
Food Service Assistant Manager
Store Assistant Manager
Store Manager in Training
Store Manager
Support Center
Employee #1 Injury Code
*
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Employee #2 Name
Employee #2 Employee #
Employee #2 Date of Hire
Employee #2 Race
Employee #2 Sex
Employee #2 Position
Select Option
Team Member
Food Service Assistant Manager
Store Assistant Manager
Store Manager in Training
Store Manager
Support Center
Employee #2 Injury Code
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Customer / Witness #1 Name
Customer / Witness #1 Phone Number
Customer / Witness #1 Injury Code
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Customer / Witness #2 Name
Customer / Witness #2 Phone Number
Customer / Witness #2 Injury Code
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Suspect #1 Race
*
Suspect #1 Sex
*
Select Option
Male
Female
Incident Person Sex
Suspect #1 Age
*
Suspect #1 Height
*
Suspect #1 Weight
*
Suspect #1 Weapon Type
*
Suspect #1 Transportation Type
*
Suspect #1 Clothing
*
Suspect #1 Features
*
Suspect #1 Injury Code
*
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Suspect #2 Race
Suspect #2 Sex
Select Option
Male
Female
Suspect #2 Age
Suspect #2 Height
Suspect #2 Weight
Suspect #2 Weapon Type
Suspect #2 Transportation Type
Suspect #2 Clothing
Suspect #2 Features
Suspect #2 Injury Code
Select Option
No Injury
Shot
Stabbed
Clubbed
Hit / Kicked
Sexual Assault
Abduction
Was Casualty Caught on Camera?
*
Select Option
Yes
No
Was Video Released to Police?
*
Select Option
Yes
No
Has Casaulty Been Reported to District Supervisor?
*
Select Option
Yes
No
Describe Casualty
*
Submit
