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 Name
Last Name
Email
*
example@example.com
Incident Date
*
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Day
-
Month
Year
Date
Ground
*
Please Select
Beaudesert
Burleigh
CBUS
Coolangatta
Coomera
Currumbin
Helensvale
Jimboomba
Mudgeeraba
Nerang
Ormeau
Parkwood
Piggabeen
Robina
Runaway Bay
Southport
Tamborine
Tugun
Other
Grade
*
Please Select
Y7 Broncos (BBOB Trophy)
Y8 Broncos (Renouf Shield)
Y9 Broncos (Hancock Cup)
Y10 A Broncos (Walters Cup)
Y10 B Broncos (De Vere Cup)
Open A Broncos (Langer Trophy)
Open B Broncos (Langer Res & Gee Shield)
Y7/8 D1 Boys Titans
Y7/8 D2 Boys Titans
Y7/8 D1 Girls Titans
Y7/8 D2 Girls Titans
Y9/10 D1 Boys Titans
Y9/10 D2 Boys Titans
Y9/10 D1 Girls Titans
Y9/10 D2 Girls Titans
Y11/12 D1 Boys Titans
Y11/12 D2 Boys Titans
Y11/12 D1 Girls Titans
Y11/12 D2 Girls Titans
Other - Put competition in your report
Select most appropriate age and competition from list
Did a Touch Judge witness the incident?
*
Yes
No
Did a Touch Judge make the initial report?
Yes
No
Offending Player Name if known
First Name
Last Name
Player Number
Offending Team
Time of Incident
*
Eg 23mins into the first half would be 1/23
Describe the incident in detail
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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?
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15.1.(a) Trips, Kicks, Strikes another player
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
15.1.(c) Drops knees first to opponent who is on the ground
15.1.(d) Use any dangerous throw when effecting a tackle
15.1.(e) Deliberately and continuously breaks the laws of the game
15.1.(f) Uses offensive or obscene language
15.1.(g) Disputes the decision of the referee or touch judge
15.1.(h) Re-enters the field of play without the permission of the referee or touch judge having previously temporarily retired from the game
15.1.(i) Behaves in any way contrary to the true spirit of the game
15.1.(j) Deliberately obstructs an opponent who is not in possession
15.1.(k) Uses a shoulder charge on an opponent
15.1.(l) Applies any unnecessary pressure or twists, including grapples, crushers or performs a 'chicken wing' style hold on a player in possession
15.1.(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 out
Trips player using ankle tap ( Safe Play Code U6 - U15)
Kicks player - Lashes out with feet in ruck
Kicks player - Uses knee or foot on player who is getting to their feet
Kicks player - Uses feet to attempt to stop try scoring opportunity
Strikes player with open hand
Strikes player with fist
Strikes player with elbow
Strikes player using Head Butt
Other
15.1.(a) Trips, Kicks, Strikes another player - Was player provoked?
Yes
No
15.1.(a) Trips, Kicks, Strikes another player - Was player the instigator?
Yes
No
15.1.(a) Trips, Kicks, Strikes another player - Was player the aggressor?
Yes
No
15.1.(a) Trips, Kicks, Strikes another player - Was player defending themself?
Yes
No
15.1.(a) Trips, Kicks, Strikes another player - Did player run from a distance?
Yes
No
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 Tackle
Swinging Arm
Crusher Tackle
Make contact with Elbow
Head Lock (Grapple)
Hair Pull
15.1.(b) - Was the Player on the ground?
Yes
No
15.1.(b) - Was the tackle :
Intentional - Meant to make contact or went out of their way to make contact
Reckless - No regard / aggressive
Careless - Accidental
Not Sure
15.1.(c) - Drops knees - Was the contact intentional?
Yes
No
Unsure
15.1.(c) - Drops knees - Was the player tackled?
Yes
No
15.1.(c) - Drops knees - Had the player surrendered?
Yes
No
15.1.(c) - Drops knees - Had the player scored a try?
Yes
No
15.1.(c) - Drops knees - Was the player attempting to score a try?
Yes
No
15.1.(c) - Drops knees - Did player slide in with knees and make contact with attacking player?
Yes
No
15.1.(d) - Dangerous Throw - Was the player put in a dangerous position?
Yes
No
15.1.(d) - Dangerous Throw - Was the player a kicker?
Yes
No
15.1.(d) - Dangerous Throw - Was the player tackled in the air?
Yes
No
15.1.(d) - Dangerous Throw - Was there hands between the players legs?
Yes
No
15.1.(d) - Dangerous Throw - Was the player driven?
Yes
No
15.1.(d) - Dangerous Throw - Was the player dropped?
Yes
No
15.1.(d) - Dangerous Throw - Did offending player(s) land on top of opposition player?
Yes
No
15.1.(d) - Dangerous Throw - How many players were in the tackle?
1
2
3
4
15.1.(f) - Offensive or Obscene Language - Was the language directed towards another player?
Yes
No
15.1.(f) - Offensive or Obscene Language - Was the language directed towards an official?
Yes
No
15.1.(f) - Offensive or Obscene Language - Was language directed towards the crowd?
Yes
No
15.1.(f) - Offensive or Obscene Language - Was the language a racial slur?
Yes
No
15.1.(f) - Offensive or Obscene Language - Was the language related to a players sexuality ?
Yes
No
15.1.(f) - Offensive or Obscene Language - Was the language a threat?
Yes
No
15.1.(h) - Player re-entering field of play - Was the player from the bench?
Yes
No
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?
Yes
No
15.1.(h) - Player re-entering field of play - Did the player get involved in a melee / scuffle or fight?
Yes
No
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
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Biting
Spitting
Eye Gouging
Pinching
Squirrel Grip
Hip Drop
Interfering with prone player
Make contact with official
Abuse Official
Coach, Water Runner, First Aid, Bench Behaviour
Action 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 incident
Touch Judge witnessed the incident
Player reported the incident
15.1.(i) - Contrary Conduct - Spitting - Was it deliberate?
Yes
No
15.1.(i) - Contrary Conduct - Spitting - Did the spit make contact with another person?
Yes
No
Other
15.1.(i) - Contrary Conduct - Spitting - Where did the Spit land?
Skin of Face or Neck
Skin of Arm or Hand
Skin of Leg
On Playing Uniform
On Ground
In the air
Unsure
Other
15.1.(i) - Contrary Conduct - Biting - Did you see bite marks?
Yes
No
15.1.(j) - Deliberately Obstructs Opponent not in possession
Pushed opponent while contesting the ball
Blocked support runner
Escort runner
Hold back support runner
Tackled player not is possession
Other
15.1.(k) - Shoulder Charge Opponent - Was contact deliberate or incidental?
Deliberate
Incidental
15.1.(k) - Shoulder Charge Opponent - Was the player in possession of the ball?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was the player hit late after offload?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was the shoulder charge on a kicker?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was the kicker in the air?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was the player in the process of scoring a try?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was contact made on the opposition players head?
Yes
No
15.1.(k) - Shoulder Charge Opponent - Was the player on the ground?
Yes
No
15.1.(l) - Applies unnecessary pressure or twists
Player performed grapple tackle
Player performed crusher tackle
Player performed chicken wing tackle
Player performed a hip-drop
Other
15.1.(m) - Forcefully spears at the legs - Was contact 1 on 1?
Yes
No
15.1.(m) - Forcefully spears at the legs - Was player 2nd or 3rd man in?
Yes
No
Please verify that you are human
*
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