Self-Checkout Discrepancy Log Form
Please record all details of any issues encountered during self-checkout transactions. Complete all fields for accurate incident logging.
Transaction Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Store Location
*
Transaction or Reference Number
*
Discrepancy Type
*
Please Select
Item not scanning
Incorrect price
Item missing from receipt
Overcharge
Undercharge
Double scan
Payment issue
Other
Item Name or Description
*
Item UPC or SKU (if available)
Amount Discrepancy (in USD)
*
Payment Method Used
*
Please Select
Cash
Debit
Credit
Mobile Payment
Gift Card
Other
Description of What Happened
*
Follow-up Notes or Actions Taken
Submit Log
Should be Empty: