CCF Referees Report

Winter 2021

Referees Name*

First Name

Last Name

Referees FFA Number

Referees Email*

Referees Phone*

Referee Appointment*

I was the CENTRE referee for this fixture I was an ASSISTANT referee for this fixture

Date/Time of Match*

:

Home*

Away*

Grade*

BPL / WPL / MAA / WAA / U16 etc

Players Club*

Players Division*

First / Res / A / B / C etc.

Players Name*

First Name

Last Name

Players FFA Number (If known)

Players Shirt Number*

Minute of Offence*

Distance from Incident (in Metres)*

How far away were you?

Was your view of the incident Impeded?*

Yes - My view WAS impeded No - My view was NOT impeded

Offence*

Degree of Offence - R1*

Serious Repeat Offence Violent tackle that endangers the safety of an opponent Rugby Tackle Violent Charging Over the ball tackle

Select the most appropriate

Degree of Offence - R2*

Violent Conduct when the ball is not in playing or playing distance Head butting Punching / Fighting Punching / Fighting (Serious) Kicking Elbow to the head Elbow to the body

Select the most appropriate

Degree of Offence - R3

Spitting AT or towards an opponent or any other person Spitting ON an opponent or any other person

Degree of Offence - R4/R5*

R4 - Sabotaging an Obvious Goal Scoring Opportunity (Hand ball) R5 - Sabotaging an obvious Goal Scoring Opportunity (Holding / Tripping / Impeding)

Select the most appropriate

Degree of Offence - R6*

Using offensive, insulting or abusing language and/or gestures in frustration Using offensive, insulting or abusing language and/or gestures direct at another person Use of discrimiatory, homophobic, racist, religious, ethnic or sexist language and/or gestures Incitement to violence, or repeated use of offensive language and/or gestures to another person Indecent actions

Select the most appropriate

Detail of Incident - All details including lead-up to the incident, what the incident entailed, behaviour after the incident and any further information that you wish to include*

Acknowledgement*

I acknowledge that the information provided above, is a true recollection on my version of the incident