Referee's Discipline Report
This form is for referees to submit any disciplinary actions taken during a match. The referee will receive a copy of this report. The referee may wish to referee the 2023-2024 Game Management Guidelines, page 7, charts around foul play.
THIS SECTION IS ABOUT THE REFEREE
Referee Name
*
First Name
Last Name
Referee Email
*
example@example.com
THIS SECTION IS ABOUT THE MATCH
Match Level
*
Men's Club
Women's Club
Men's College
Women's College
Boys HS Div I
Boys HS Div II
Girls HS Div I
Girls HS Div II
Boys Grade 7/8
Girls Grade 7/8
Coed Grad 5/6
Flag Grade 2/3/4
Date of Match
*
-
Month
-
Day
Year
Date
Venue
*
Home Team
*
Away Team
*
if out of state team, please note state in parenthesis (CA)
Final Score
*
THIS SECTION IS ABOUT THE INCIDENT
Player Name
*
Player Team
*
Action Taken
*
Yellow Card
2nd Yellow Card / Red Card
Red Card
Time elapsed in match when incident occurred
*
Was the incident reported by an Assistant Referee?
*
No
Yes
If Yes, please include AR Name and Email Address
Select ALL applicable laws
*
9.1-9.6 Obstruction
9.7 Unfair Play
9.8-9.10 Repeated Infringements
9.11 Dangerous Play (dangerous or reckless play)
9.12 Dangerous Play (physical abuse)
9.12 Dangerous Play (verbal abuse)
9.13 Dangerous Play (dangerous tackle)
9.14-915 Tackling Player Without The Ball
9.16 No Wrap Tackle or Tackle Attempt
9.17 Playing Person In The Air
9.18 Tip/Dump Tackle
9.19 Dangerous Play In The Scrum
9.20 Dangerous Play In Ruck Or Maul
9.21 Retaliation
9.22 Cavalry Charge or Flying Wedge
9.23 Kicking Ball From Ball Carriers Hands
9.24 Dangerous Fend or Fend To The Face
9.25 Charge or Obstruct Kicker
9.29 Not Safely Lowering Lifted Teammate
9.27 Misconduct
9.28 Match Official Abuse
Other
Description of incident
*
Was there direct contact with the head?
*
Yes
No
Unsure
Does not apply
Was it? (Check all that apply)
*
Intentional
Reckless
Avoidable
Accidental
Direct Contact
Indirect Contact
High Force
Low Force
Repeated Infringement
Other
How would you rate the level of severity of the incident?
*
Minimal
Moderate
Severe
Was the other player injured?
*
Yes
No
Usure
What was the player's reaction to being cautioned/suspended (yellow) or sent off (red)?
*
include reaction when returning from yellow. Did they apologize, accept reasonability, show concern for another player, were they defiant, abusive, etc.?
Please report any aggravating factors, if any
Please report any mitigating factors, if any
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Is there another discipline report for this match?
*
Yes
No
Submit
Should be Empty: