Full Name*

Role*

Email*

example@example.com

Competition*

Home Team*

Away Team*

Grade/ Age Group*

Division*

Venue

Date and Kick Off Time*

Date Hour Minutes AM/PM Option

Person Reported

Role

Club

Players Shirt Number

Time of Incident

What are you reporting?*

Was the offence against a Match Official?*

Yes No

Red Card*

R1- Serious Foul Play R2- Violent Conduct R3- Spitting R4- Denying an Obvious Goal Scoring Opportunity by Use of The Hand R5- Denying an Obvious Goal Scoring Opportunity R6- Verbal Abuse R7- Accumulation of 2 Yellow Cards

Did you see the incident clearly*

Yes No

Level of Force*

High Force Medium Force Low Force

Further Information*

Player received medical treatment Player returned to the game Player didn't return to the game

Where was the contact on the body?*

Was the contact made with studs?*

Yes No

Further Details of tackle*

Please describe the tackle, did the player jump in, how many feet were used in the tackle?

Level of Force*

High Medium Low

Offending player made contact with*

Did the player use; Hand, elbow foot etc

If fist, open or closed hand (Punch or slap)

To the opponents (Head, Neck etc)*

If a player missed, please put where it was aimed for

Did the strike connect?*

Yes No

Further information to the incident*

Did the spit make contact with someone?*

Yes No

Where did the spit make contact?*

What was said?*

Please use exact words/ phrases. Do not cut out offensive words.

Did the player commit a further offence after being sent off? (Swearing, violent conduct, refusing to leave the pitch etc)*

What was the problem with the ground?*

Weather affected - not safe/suitable Field of Play not safe/suitable Markings not acceptable Other- (Give details below)

When did the incident occur?*

Pre game During game Post game

Reason for abandoned match*

Other report options*

Colour Clash Match starting late Report on facilities Other not listed

Please add any extra information regarding the incident

Please enter any comments/ extra information you wish to add to this report.

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