Gaming Referee Assault Form
Date of game
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Game Number
Home Team & Colour
Away Team & Colour
League/Competition
Division/Age Group
Kickoff Time
Hour Minutes
AM
PM
AM/PM Option
Field/City
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When did the incident occur?
Please Select
Before the game
During the first half
At half-time
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
Referee Information
Rows
Were they assaulted?
Name?
Under 18?
Reg #?
Phone?
Email?
Referee
Assistant 1
Assistant 2
4th Official
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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
First Name
Last Name
Submit
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