POSITIVE ENVIRONMENT PROGRAM INCIDENT REPORTING FORM

Please note that should code of conduct charges be issued as a result of this report you may be required to appear in person at any hearing required to determine an outcome in the matter.

Name of person making report: (required)

Mobile number of person making report: (required)

Email of person making report: (required)

Name of person(s) being alledged to have breached the code of conduct? (required)

Which club is this person(s) being alledged to have breached the code of conduct a member of, or associated with?

Date of Incident:

Time of Incident:

Venue where incident took place:

Home team:

Away Team:

Age Group/Division:

Was this a Verbal Attack/Verbal Altercation?

Yes No

Yes

Was this a Physical Attack/Physical Altercation?

Yes No

Yes

Did the incident involve unauthorised entry into the playing area and/or entry onto the field of play?

Yes No

Yes

Was this Match Temporarily Stopped?

Yes No

Yes

Was this Match Abandoned?

Yes No

Yes

Insert and format text, links, and images here.

Where the Police called as a result of the incident?

Yes No

Yes

Did the person(s) refuse/ignore the reasonable direction of the Ground Manager or any other Match/League Official?

Yes No

Yes

Did the person behave in a way contrary to the Code of Conduct and/or the spirit of the game?

Yes No

Yes