Loss Prevention

Incident Report For:

Type of Incident *

This information is highly sensitive and will be handled as such. All Data will be kept confidential, and the reporting Team Member will remain anonymous.

Name of Team Member Reporting *

First

Last

Name of Team Member Reporting *

First

Last

Your name will only appear here and not on further communication

Location *

Store Number *

Store Location Email *

Date / Time Theft Occurred *

Date

Time

Field Coach *

Date / Time Vandalism Occurred *

Date

Time

Date / Time Injury Occurred *

Date

Time

Date / Time Incident Occurred *

Date

Time

Name of Team Member who answered the call *

First

Last

Description of Incident *

Please be as detailed as possible.

Description of Incident *

Please be as detailed as possible. Include the name and any descriptions that will help in identifying the subject.

Was there a witness? *

Yes
No

Name of Witness *

First

Last

Phone Number of Witness (if available) *

Was there a victim other than The Kent Companies? *

Yes
No

Please fill out the following fields for victims other than The Kent Companies

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Phone

Were police called? *

Yes
No

Case Number *

Were there any injuries? *

Yes
No

Was EMS dispatched? *

Yes
No

Was EMS requested by the injured party? *

Yes
No

Please describe the extent of the injuries: *

Please list the items taken: *

Please list the items vandalized: *

Injured Party Information

Name *

First

Last

Date of Birth *

Date

Time

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Phone Number *

Contact Phone Number

Description of Suspect(s) *

Description of Vehicle and License Plate Number *

Details of Call

Caller ID *

Accent of Caller *

Gender of Caller *

Length of Caller *

Narrative of what happened. Please describe in as much detail as possible. *

Narrative of what was said during the call. Please describe in as much detail as possible. *

Please upload pictures of vandalism; case card or anything received from the police; voided receipt of all items that were stolen, with the total value.