Refusal of Service & Guest Incident Report

Please complete and submit this form any time someone is refused service, or for any other incident involving a guest that should be recorded.

Report submitted by *

First

Last

Date / Time *

Date

Time

Location *

Summary of incident and action taken *

Name of guest (if known)

First

Last

Guest's address (if known)

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Name of server or bartender *

First

Last

Witness(es) - Include phone numbers if available.

Manager on Duty *

First

Last

Service refused by (if applicable)

First

Last

Was there a bar tab? (If yes, please scan and attach below)

• Yes
• No

Was the guest alone?

• Yes
• No

Description of guest's clothing

Condition of guest's clothing (check all that apply)

• Orderly
• Disarranged
• Soiled
• Other (describe below)

Describe condition of clothing (other) *

Alcohol on breath?

• None
• Faint
• Moderate
• Strong

Guest's behavior (check all that apply)

• Carefree
• Cocky
• Combative
• Cooperative
• Indifferent
• Insulting
• Polite
• Profane
• Sleepy
• Talkative
• Other (describe below)

Describe guest behavior (other) *

Appearance of guest's eyes (check all that apply)

• Clear
• Watery
• Glassy
• Bloodshot

Guest's complexion (check all that apply)

• Normal
• Flushed
• Pale

Guest's speech (check all that apply)

• Good
• Fair
• Confused
• Mumbled
• Mush-mouthed
• Slurred
• Other (describe below)

Describe guest's speech *

Unusual actions by guest (check all that apply)

• Belching
• Fighting
• Hiccuping
• Laughing inappropriately
• Vomiting
• Other (describe below)

Describe other unusual actions. *

Did the guest drive?

• Yes
• No
• Not known

Attach an image of the guest's tab (if available)

Click or drag files to this area to upload. You can upload up to 4 files.

Submit