Referee Incident Report Form All incidents must be submitted to Football West using this form by 12:00pm the next business day following the match. Please complete this form as accurately as possible. As you work through the form, more options will appear. Personal DetailsReferee's Status* Official Referee Club Referee Referee's Name* First Last Referee's FFA Number*Official referees only Referee's Phone Number*To contact for clarification if required Email address* Match DetailsDuty*RefereeAssistant RefereeFourth OfficialReferee AssessorMatch type*LeagueCupFriendlyCompetition*FFA CupState Reserves CupState Under 18 CupAmateur CupAmateur Reserves CupWomen's State CupWomen's Metro CupMetropolitan CupMasters CupJuniors Under 18 CupJuniors Under 16 CupJuniors Under 15 CupJuniors Under 14 CupJuniors Under 13 CupJuniors Under 12 CupGirls Under 17 CupGirls Under 15 CupGirls Under 14 CupGirls Under 13 CupCompetition*NPLWA Men's/Women'sNPLWA JuniorsState LeagueWomen's LeagueAmateur LeagueMetropolitan LeagueMasters LeagueJuniors LeagueSchoolsFutsal LeagueWACFAKick It. World CupOtherGrade*First TeamUnder 23Under 20Under 18Grade*Under 16Under 15Under 14Under 13Grade*Div 1 First TeamDiv 1 ReservesDiv 1 Under 18Div 2 First TeamDiv 2 ReservesDiv 2 Under 18Grade*Premier First TeamPremier ReservesDiv 1 First TeamDiv 1 ReservesCentral DivisionNorth Div 1North Div 2North Div 3South Div 1South Div 2South Div 3Grade*Premier First TeamPremier ReservesDiv 1 First TeamDiv 1 ReservesDiv 2 First TeamDiv 2 ReservesDiv 3 First TeamDiv 3 ReservesDiv 4 First TeamDiv 4 ReservesDiv 5 First TeamDiv 5 ReservesGrade*Central DivisionNorth Div 1North Div 2North Div 3North Div 4North Div 5South Div 1South Div 2South Div 3South Div 4Grade*Central DivisionNorth Div 1North Div 2North Div 3South Div 1South Div 2South Div 3O45 Group AO45 Group BAge, Grade & Division* Date of match* DD slash MM slash YYYY Scheduled kick off* : Hours Minutes AM PM Venue* Home Team* Away Team* Report DetailsReport type*Player, substitute or substituted player sent offTeam official sent offMatch fails to commenceMatch abandoned after commencementBefore or after match incidentDuring match incidentOther incidentReported person (if known)* Club Shirt number* FFA Number (if known)* Time of offence (minute)* Sending-off offence*Denying the opposing team a goal or an obvious goal-scoring opportunity by a handball offence (except a goalkeeper within their penalty area)Denying a goal or an obvious goal-scoring opportunity to an opponent whose overall movement is towards the offender's goal by an offence punishable by a free kickSerious foul playBiting or spitting at someoneViolent conductUsing offensive, insulting or abusive language and/or gesturesReceives a second caution in the same matchSending-off offence*Delaying the restart of play by the opposing teamDeliberately leaving the technical area to show dissent towards, or remonstrate with, a match official or to act in a provocative or inflammatory mannerEnter the opposing technical area in an aggressive or confrontational mannerDeliberately throwing/kicking an object onto the field of playEntering the field of play to confront a match official (including at half-time and full-time) or to interfere with play, an opposing player or match officialPhysical or aggressive behaviour (including spitting or biting) towards an opposing player, substitute, team official, match official, spectator or any other personReceiving a second caution in the same matchUsing offensive, insulting or abusive language and/or gesturesUsing unauthorised electronic or communication equipment and/or behaving in an inappropriate manner as the result of using electronic or communication equipmentViolent conductOtherWas this or any further offence committed against a match official? Yes Full description of the offence committed*If the person has committed any further offences, please ensure all details are included.Before or after match incident* Before match incident involving a Player Before match incident involving a Team/Club Official Before match incident involving a Spectator After match incident involving a Player After match incident involving a Team/Club Official After match incident involving a Spectator During match incident* During match incident involving a Team/Club Official During match incident involving a Spectator Collective shows of dissent (on field) Match fails to commence* Weather affected Field of play not safe/suitable Markings not acceptable Lighting insufficient for play Colour clash Other Match abandoned after commencement* Weather affected Field of play not safe/suitable Light failure or insufficient for play Team reduced to less than seven players Player/team official causes the abandonment Spectator interference Other Full description of the incident*
