Gaming Referee Assault Form
Date of game
Home Team & Colour
Away Team & Colour
When did the incident occur?
Before the game
During the first half
During the second half
After the game
Did the incident involve the following? Select any that may apply
Intimidating and/or threatening behaviour
Misconduct involving racist or sexist comments
Language and/or profanity directed at a match official
Any form of excessive physical assault
Attempted abuse of a match official
If name of the parties involved are known, indicate who they were and position
Were they assaulted?
Use the space below to provide a thorough description of the assault. You must complete a SEPARATE report for EACH incident. Ensure that the description is as detailed as possible. Include the following information if it is applicable to your situation: players involved, location on the field, comments that were exchanged, the manner in which the parties involved acted, the tone of voice, if match was abandoned, and if so, at what point in the match, director you were facing, proximity, if anyone entered the field of play, etc.
Reporting Officials Name
Should be Empty: