Player / Official Report Incident Statement Submission Form

Player / Official Report - Incident Statement Submission

To be completed by the Club Secretary, Incident Officer or President ONLY. Please note the SMJFL will only accept one form per reported incident.
THIS IS NOT THE CLUB COMPLAINT FORM AND CLUB COMPLAINTS SHOULD NOT BE SUBMITTED THROUGH THIS FORM.

You should only be submitting statements in relation to reportable offences that you have been notified about by the SMJFL.
You are confirming that you have been contacted by the SMJFL in regards to an incident/report where you have been requested to submit a statement via this form.*

Yes, the SMJFL are aware of this and we have been requested to provide statements via this form.We have not been requested to supply statements by the SMJFL in relation to this offence
You may need to submit a Club Complaint form. Should you require any advice on this, please reach out to the General Manager of Football Operations Nathan Broadbent via gmfootball@smjfl.com.au
Name of person submitting this form*

First NameLast Name
Club of person completing this form *
Role at club*
Are you from the reported person's club*

YesNo
Phone Number*
Email*
example@example.com
Does this form include any attachments? (i.e. Video clip, picture) Note: Option to upload supporting documents etc is provided at the end of this form*

YesNo
Please confirm you are the primary Club contact in relation to this report*

Yes, I understand and confirm I am the primary Club contact in relation to this reportOther

Details of Match
Date of Match*

DayMonthYear
Date
SMJFL Round*
Venue*
Scheduled Match Start Time*

Hour Minutes

AM/PM Option
Age Group*
Competition*
Division*
Complainant Club*
Name of club lodging the complaint/incident
Opposition Club*
Respondant Club
Quarter incident occurred*

First QuarterSecond QuarterThird QuarterFourth QuarterFirst Half (Welcome Back to Footy/Lightning Carnival)Second Half (Welcome Back to Footy/Lightning Carnvial)Other (Practice Matches)
Quarter incident occurred (In case of practice match with more than 4 quarters)*
Type which period the incident occured in

Details of Reported Person

Fill out this section if you are from the club of the person who has been reported
Name of Reported Person*

First NameLast Name
Reported persons role at club*
Player Number*
Reported Offence (As advised by the SMJFL)
22.2.2 (a) Intentionally or Carelessly

IntentionallyCarelesslyUnsure

Details of Witness Club

Fill out this section if you are the Club involved in the report BUT NOT the reported club (i.e. not player who has been struck)
Name of person involved - If you do not have the name of the person involved, please enter their role (e.g., SMJFL Umpire, Club Volunteer Umpire, Away Team Manager etc.)*

First NameLast Name
Age Group
Division
Person's role at club*
Player Number
Other (If not listed)

Witness statement #1

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Did this person witness the incident?*

Yes, this person witnessed the incidentNo, they did not witness the incident
As you have selected no, you will need to choose another witness who did see the incident, then select yes, OR select 'No witness statement' and submit the form.*

No Witness statement
Person's relation to club*
Person's relation to club (if not listed)
Player's jumper number *
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box*
Did you wish to enter another witness statement?

YesNo

Witness statement #2

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Did this person witness the incident?

Yes, this person witnessed the incidentNo, they did not witness the incident
As you have selected no, you will need to choose another witness who did see the incident, then select yes, OR select 'No witness statement' and submit the form.

No Witness statement
Person's relation to club
Person's relation to club (if not listed)
Player's jumper number
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box
Did you wish to enter another witness statement?

YesNo

Witness statement #3

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Did this person witness the incident?

Yes, this person witnessed the incidentNo, they did not witness the incident
As you have selected no, you will need to choose another witness who did see the incident, then select yes, OR select 'No witness statement' and submit the form.

No Witness statement
Person's relation to club
Person's relation to club (if not listed)
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box
Player's jumper number

Click to submit the form.

By submitting, you agree that you have filled out this form with true and accurate information and have not falsified or entered misleading information.
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Player / Official Report - Incident Statement Submission