GCRLRA School Games Send Off / Report Form

GCRLRA School Games Send Off / Report Form

This form must be completed for each individual whenever you have dismissed a player or need to report any other type of incident.
Officials Name*

First NameLast Name
Email*
example@example.com
Incident Date*

DayMonthYear
Date
Ground*
Grade*
Select most appropriate age and competition from list
Did a Touch Judge witness the incident?*

YesNo
Did a Touch Judge make the initial report?

YesNo
Offending Player Name if known

First NameLast Name
Player Number
Offending Team
Offending Grade
Time of Incident*
Eg 23mins into the first half would be 1/23
Describe the incident in detail*
Be very specific and descriptive in your report. Include any other identifiable features if not a player. Use the exact wording that was used (including swear words) if applicable.
Choose all charges that apply?*

15.1.(a) Trips, Kicks, Strikes another player15.1.(b) When effecting or attempting to effect a tackle makes contact with the head or neck of an opponent intentionally, recklessly or carelessly15.1.(c) Drops knees first to opponent who is on the ground15.1.(d) Use any dangerous throw when effecting a tackle15.1.(e) Deliberately and continuously breaks the laws of the game15.1.(f) Uses offensive or obscene language15.1.(g) Disputes the decision of the referee or touch judge15.1.(h) Re-enters the field of play without the permission of the referee or touch judge having previously temporarily retired from the game15.1.(i) Behaves in any way contrary to the true spirit of the game15.1.(j) Deliberately obstructs an opponent who is not in possession15.1.(k) Uses a shoulder charge on an opponent15.1.(l) Applies any unnecessary pressure or twists, including grapples, crushers or performs a 'chicken wing' style hold on a player in possession15.1.(m) Forcefully spears at the legs of a player in possession, exposing them to unnecessary risk of injury (Cannon Ball)
15.1.(a) Trips, Kicks, Strikes another player

Trips player by sticking foot outTrips player using ankle tap ( Safe Play Code U6 - U15)Kicks player - Lashes out with feet in ruckKicks player - Uses knee or foot on player who is getting to their feetKicks player - Uses feet to attempt to stop try scoring opportunityStrikes player with open handStrikes player with fistStrikes player with elbowStrikes player using Head ButtOther
15.1.(a) Trips, Kicks, Strikes another player - Was player provoked?

YesNo
15.1.(a) Trips, Kicks, Strikes another player - Was player the instigator?

YesNo
15.1.(a) Trips, Kicks, Strikes another player - Was player the aggressor?

YesNo
15.1.(a) Trips, Kicks, Strikes another player - Was player defending themself?

YesNo
15.1.(a) Trips, Kicks, Strikes another player - Did player run from a distance?

YesNo
15.1.(b) When effecting or attempting to effect a tackle makes contact with the head or neck of an opponent intentionally, recklessly or carelessly - How was contact made?

Head High TackleSwinging ArmCrusher TackleMake contact with ElbowHead Lock (Grapple)Hair Pull
15.1.(b) - Was the Player on the ground?

YesNo
15.1.(b) - Was the tackle :

Intentional - Meant to make contact or went out of their way to make contactReckless - No regard / aggressiveCareless - AccidentalNot Sure
15.1.(c) - Drops knees - Was the contact intentional?

YesNoUnsure
15.1.(c) - Drops knees - Was the player tackled?

YesNo
15.1.(c) - Drops knees - Had the player surrendered?

YesNo
15.1.(c) - Drops knees - Had the player scored a try?

YesNo
15.1.(c) - Drops knees - Was the player attempting to score a try?

YesNo
15.1.(c) - Drops knees - Did player slide in with knees and make contact with attacking player?

YesNo
15.1.(d) - Dangerous Throw - Was the player put in a dangerous position?

YesNo
15.1.(d) - Dangerous Throw - Was the player a kicker?

YesNo
15.1.(d) - Dangerous Throw - Was the player tackled in the air?

YesNo
15.1.(d) - Dangerous Throw - Was there hands between the players legs?

YesNo
15.1.(d) - Dangerous Throw - Was the player driven?

YesNo
15.1.(d) - Dangerous Throw - Was the player dropped?

YesNo
15.1.(d) - Dangerous Throw - Did offending player(s) land on top of opposition player?

YesNo
15.1.(d) - Dangerous Throw - How many players were in the tackle?

1234
15.1.(f) - Offensive or Obscene Language - Was the language directed towards another player?

YesNo
15.1.(f) - Offensive or Obscene Language - Was the language directed towards an official?

YesNo
15.1.(f) - Offensive or Obscene Language - Was language directed towards the crowd?

YesNo
15.1.(f) - Offensive or Obscene Language - Was the language a racial slur?

YesNo
15.1.(f) - Offensive or Obscene Language - Was the language related to a players sexuality ?

YesNo
15.1.(f) - Offensive or Obscene Language - Was the language a threat?

YesNo
15.1.(h) - Player re-entering field of play - Was the player from the bench?

YesNo
15.1.(h) - Player re-entering field of play - Had the player been dismissed or was in the Sin Bin at the time of the incident?

YesNo
15.1.(h) - Player re-entering field of play - Did the player get involved in a melee / scuffle or fight?

YesNo
15.1.(h) - Player re-entering field of play - Approximately how far did the player encroach on the field?
15.1.(i) - Contrary Conduct - Choose all that apply*

BitingSpittingEye GougingPinchingSquirrel GripHip DropInterfering with prone playerMake contact with officialAbuse OfficialCoach, Water Runner, First Aid, Bench BehaviourAction not in the true spirit of the game (Must be selected)Other
15.1.(i) - Contrary Conduct - How did you become aware of the incident?

I witnessed the incidentTouch Judge witnessed the incidentPlayer reported the incident
15.1.(i) - Contrary Conduct - Spitting - Was it deliberate?

YesNo
15.1.(i) - Contrary Conduct - Spitting - Did the spit make contact with another person?

YesNoOther
15.1.(i) - Contrary Conduct - Spitting - Where did the Spit land?

Skin of Face or NeckSkin of Arm or HandSkin of LegOn Playing UniformOn GroundIn the airUnsureOther
15.1.(i) - Contrary Conduct - Biting - Did you see bite marks?

YesNo
15.1.(j) - Deliberately Obstructs Opponent not in possession

Pushed opponent while contesting the ballBlocked support runnerEscort runnerHold back support runnerTackled player not is possessionOther
15.1.(k) - Shoulder Charge Opponent - Was contact deliberate or incidental?

DeliberateIncidental
15.1.(k) - Shoulder Charge Opponent - Was the player in possession of the ball?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was the player hit late after offload?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was the shoulder charge on a kicker?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was the kicker in the air?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was the player in the process of scoring a try?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was contact made on the opposition players head?

YesNo
15.1.(k) - Shoulder Charge Opponent - Was the player on the ground?

YesNo
15.1.(l) - Applies unnecessary pressure or twists

Player performed grapple tacklePlayer performed crusher tacklePlayer performed chicken wing tacklePlayer performed a hip-dropOther
15.1.(m) - Forcefully spears at the legs - Was contact 1 on 1?

YesNo
15.1.(m) - Forcefully spears at the legs - Was player 2nd or 3rd man in?

YesNo
Please verify that you are human*
Should be Empty: