Discipline Incident Report

MATCH INCIDENT REPORT FORM

For Clubs
Your Name*

First NameLast Name
E-mail*
Contact Number*
Club Name:*
Which club are you from?
Role at Club:*
Football Victoria (FV) takes all reports seriously however, matters reported without contact information provided or with insufficient evidence may not be able to be followed up.

Personal contact information will not be shared with any other party.

Your Incident Report may be shared with relevant individuals who are invited to respond to allegations made against them.
Incident Information
Date of Incident:*

DayMonthYear
Date
Competition Type:

JuniorsSeniorsOther
Senior League:
Junior League:
Home Club/Team:
If you cannot find a club in this drop down list, please select 'NOT LISTED' and inform us later in this form.
Away Club/Team:
If you cannot find a club in this drop down list, please select 'NOT LISTED' and inform us later in this form.
Have you informed your Club of this Incident?

YesNo
Type of Incident:

RacismViolent Conduct (e.g. Melee or Brawl)Offensive and/or Abusive LanguageOffence against a Match OfficialOther
Who was the racial abuse directed at?

Fill out this section if you witnessed racial abuse directed at yourself or someone else.
Full Name

First NameLast Name
Club
What Club are they from?
Role at Club:
Racism Offender(s)

Description of who the offender is.
Full Name:

First NameLast Name
Club:
What Club is the offender from?
Role at Club:
Shirt Number:
Complete if offender was a player.
Description of the Offender:*
Please be as specific as possible e.g. Hair Colour/Clothes/Age Bracket
Incident
What happened? Please describe the incident.*
Please quote & use exact words where necessary as well as names & description of offenders. (e.g. Player Number)
Was the referee aware or made aware of the incident?

YesNoNot Sure
Was the opposition club aware or made aware of the incident?

YesNoNot Sure
Did anyone else witness the incident? If Yes, please provide contact information below.

YesNoNot Sure
Would you be prepared to give evidence at an Independent Tribunal hearing if asked?

YesNoNot Sure
Additional information:
Additional Statements:
If you have any photo's, video footage or further witness statement's in regards to the incident, please attach all files in the above section. Otherwise, please email to discipline@footballvictoria.com.au.
Should you have any questions, or need any help completing the form, please let us know at discipline@footballvictoria.com.au.
Should be Empty:

MATCH INCIDENT REPORT FORM

For Clubs

Incident Information

Who was the racial abuse directed at?

Racism Offender(s)

Incident