Witness / Involved Party Statement

This form is to be completed by each witness / involved party. Fields marked with * are required.

1. Email *

Location Information

Select your venue (optional — auto-fills fields below)

2. Legal Name of the Location

3. The DBA of the Location *

4. Address of Location *

5. Calendar Date of incident *

After midnight is counted as the next calendar day

6. Date Submitted *

7. Time of incident. *

8. Type of Incident *

Information of Person Completing This Statement

9. Your Full Name (Your Legal Name) *

10. Your Address *

11. Your phone number *

12. Type *

WitnessInvolved Person

Describe the Incident in Your Own Detailed Words

Please include the what happened prior to the incident, what happened during the incident, your involvement in the incident, who else was involved in the incident and what was the conclusion of the incident.

13. Use this section to fully, and in detail, describe the event in your own words. *

14. Please load any photos or video recordings you may have here.

Choose FileNo file chosen

15. By selecting "I Accept" using any device, means, or action, you affirm that the statements in this form are true and accurate to the best of your information, knowledge, and belief. You further agree that your signature on this document (hereinafter your "E-Signature") is valid, just as if you had signed the document in writing. *

I acceptI have decided to opt out of "E-signature" and will print out and physically sign the incident report.