Incident Report Form
CL Staff to complete this form for any incidents involving injuries, security issues, or other incidents which must be formally recorded. Be sure to collect contact information of any person(s) who are injured on the property including FULL NAME, PHONE #. Incident reports are confidential.

Person Completing This Form:

Reporting Employee name

Staff Witnesses

Witness Employee's name (if any)
Click + to add another witness

Other Witness(es)

Other Witness Name (if any)
Click + to add another witness

About Incident

Date & Time of incident
Please be as close to the time as possible so that we can locate surveillance footage of the incident if needed.
Location of Incident
BE SPECIFIC - (i.e. in lobby near the front glass doors or Bellazzo right in front of the bar)
What is the nature of the incident?
Did you ask the individual if they wanted medical care from 911?
Please provide as much detail as possible about this incident including times, locations, and who was present, and what happened. Please provide step by step details about any actions taken by you or other CL staff.
Was Police/Fire/EMT required?
Was Chateau Luxe Security contacted at the time of this incident?
Was the Chateau Luxe Manager on Duty contacted at the time of this incident?
Name of Person #1 involved in this incident
Person #1 is
#2 Name of person involved in this incident
Person #2 is
#3 Name of person involved in this incident
Person #3 is
#4 Name of person involved in this incident
Person #4 is
If there were additional people involved, list them below along with any other additional details you wish to share.
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
Max file size = 5mb
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
Max file size = 5mb
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