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Gas Station Incident Report
Submit Dip
Gas Station Incident Report
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2025-10-07T09:21:12+00:00
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Step
1
of 2
1. Report Information
Date / Time of incident
*
Date
Time
Manager Completing Report
*
Select Gas Station
*
--- Select Choice ---
Revelstoke
Penticton
West Kelowna
Williams Lake
Marysville
Prince Rupert
Nanaimo
2. Incident Details
Date of Incident
*
Date
Time
Type of Incident
Theft / Robbery
Customer Complaint / Altercation
Employee Misconduct
Accident / Injury
Property Damage
Safety / Hazardous Material
Other
Other
Brief Description of Incident
3. People Involved
Employee(s) Involved
Customer(s) / Third Party Involved
Contact Information (if available)
Next
4. Actions Taken
Immediate Actions Taken by Staff/Manager
Emergency Services Contacted
Police
Fire
Ambulance
None
Police File Number (if applicable)
Officer’s Name & Badge Number (if available)
5. Injury / Medical
Was anyone injured?
*
--- Select Choice ---
Yes
No
Who
Type of injury
First Aid Provided?
*
--- Select Choice ---
Yes
No
Hospital / Clinic involved?
*
--- Select Choice ---
Yes
No
6. Follow-Up / Next Steps
Repairs / Cleanup Required
*
--- Select Choice ---
Yes
No
Insurance Notified
*
--- Select Choice ---
Yes
No
Photos Taken
*
--- Select Choice ---
Yes
No
File Upload
Drag & Drop Files,
Choose Files to Upload
You can upload up to 10 files.
Video Footage Saved
*
--- Select Choice ---
Yes
No
Further Action Required
*
--- Select Choice ---
Yes
No
7. Sign-Off
Signature
Clear Signature
Date / Time
Date
Time
Supervisor / Head Office Review
Review Date
Date
Time
Date Station Photos
Submit
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