INCIDENT REPORT FORM
PLEASE KEEP A COPY OF THIS COMPLETED FORM IN YOUR FILES AND MAIL A COPY TO
CMAC, c/o Hinman & Carmichael LLP, 260 California Street, # 1001, San Francisco, CA 94111
DATE: ___________ TIME: _________ VENUE: _________________
ADDRESS OF VENUE: ______________________________________
ABC LICENSE TYPE: __________
SF ENTERTAINMENT PERMITS: ________________________________
WEATHER CONDITIONS: ______________________________________
SIDEWALK AND EXTERIOR CONDITIONS [TRAFFIC, PEDESTRIANS, LINES, CROWDS, ETC.]:
_________________________________________________________________________________
1. DESCRIBE INCIDENT [NARRATIVE, USE ADDITIONAL SHEETS IF NECESSARY]:
_________________________________________________________________________________
2. NAME OF PERSON ARRESTED/STOPPED/QUESTIONED [INCLUDE ADDRESS/PHONE/EMAIL ADDRESS]:________________________________________________________________________
3. PHYSICAL DESCRIPTION OF PERSON [AGE, HEIGHT, WEIGHT, HAIR/EYE COLOR, DRESS]: __________________________________________________________________________________
4. WAS IDENTIFICATION ASKED FOR? ________ WAS IDENTIFICATION SHOWN? ___________
5. DESCRIBE IDENTIFICATION [TYPE, PHYSICAL DESCRIPTION, AGE SHOWN, ETC.]
____________________________________________________________________
6. DID INDENTIFICATION MATCH PERSON? ____________________________________________
7. STATEMENTS OF PERSON [USE ADDITIONAL SHEETS IF NECESSARY]: __________________________________________________________________________________
__________________________________________________________________________________
8. NAME, AGENCY AND BADGE [STAR] NUMBER OF OFFICER: ___________________________ __________________________________________________________________________________
9. DESCRIPTION OF OFFICER [AGE, HEIGHT, WEIGHT, HAIR/EYE COLOR, DRESS (UNIFORM OR PLAIN CLOTHES)]: _______________________________________________________________________
10. OFFICER STATEMENTS [USE ADDITIONAL SHEETS IF NECESSARY: __________________________________________________________________________________ __________________________________________________________________________________
11. CRIMINAL OR ADMINISTRATIVE SECTION CITED BY OFFICER AS BASIS FOR ACTION: _____________________________________________________________________________
12. DISPOSITION OF MATTER [ARREST AND IN CUSTODY, WARNING, CITATION OR NO ACTION – ATTACH COPY OF CITATION IF ONE ISSUED]: ___________________________________________________________________________
13. WAS INCIDENT VIDEOTAPED BY SECURITY CAMERAS OR PERSONAL CELLPHONE (IF YES, WHERE IS COPY OF VIDEO?]: _____________________________________________________________________________
14. WAS ANY TESTING EQUIPMENT USED BY OFFICERS [NOISE METERS, ETC.]? IF SO PLEASE DESCRIBE:
_______________________________________________________________________
15. WERE YOU FURNISHED WITH COPIES OF TEST RESULTS? [IF SO PLEASE ATTACH]:_______________________________________________________________
16. PLEASE DESCRIBE YOUR ASSESSMENT OF THE OFFICERS [POLITE? THREATENING? PROFESSIONAL? OTHER?]: _______________________________________________________________________
17. DID THE OFFICERS ASK TO COME IN OR DID THEY JUST ENTER?
_______________________________________________________________________
18, DID YOU OR ANY MEMBER OF YOUR STAFF INVITE THE OFFICER TO ENTER?
ANY OTHER INFORMATION THAT IS RELEVANT [I.E., PRIOR EXPERIENCE WITH OFFICER, PRIOR INCIDENTS WITH OFFICER, HISTORY OF PRIOR CITATIONS, ETC.]:
__________________________________________________________
Person completing form:
name: ________________________________
title: __________________________________
venue: ________________________________
cell: _________________________________
email: ________________________________
reviewed by: _____________________(owner)