Vilification Incident Form

Vilification Incident Form

To be completed by the Club Secretary, Incident Officer or President ONLY. Please note the SMJFL will only accept one form per reported vilification incident.
THIS IS NOT THE CLUB COMPLAINT FORM AND CLUB COMPLAINTS SHOULD NOT BE SUBMITTED THROUGH THIS FORM.
Yes, the SMJFL are aware of this and we have been requested to provide statements via this form.We have not been requested to supply statements by the SMJFL in relation to this offence
You may need to submit a Club Complaint form. Should you require any advice on this, please reach out to the General Manager of Football Operations Nathan Broadbent via gmfootball@smjfl.com.au
Name of person submitting this form*

First NameLast Name
Club of person completing this form *
Role at club*
YesNo
Phone Number*
Format: 0400000000.
Email*
example@example.com
YesNo
Yes, I understand and confirm I am the primary Club contact in relation to this reportOther

Details of Match
Date of Match*

DayMonthYear
Date
SMJFL Round*
Venue*
Scheduled Match Start Time*

Hour Minutes

AM/PM Option
Age Group*
Competition*
Division*
Complainant Club*
Name of club lodging the complaint/incident
Opposition Club*
Respondant Club
First QuarterSecond QuarterThird QuarterFourth QuarterFirst Half (Welcome Back to Footy/Lightning Carnival)Second Half (Welcome Back to Footy/Lightning Carnvial)Other (Practice Matches)
Quarter incident occurred (In case of practice match with more than 4 quarters)*
Type which period the incident occured in

Details of Alleged Offender Person

Fill out this section if you are from the club of the person who is the alleged offender
Name of Alleged Offender Person*

First NameLast Name
Offenders role at club*
Player Number (if applicable)*
Reported Offence (As advised by the SMJFL)
IntentionallyCarelesslyUnsure

Details of Witness Club

Fill out this section if you are the Club involved in the alleged vilification BUT NOT the alleged offending club (i.e. not player who has been struck)
Name of person involved - If you do not have the name of the person involved, please enter their role (e.g., SMJFL Umpire, Club Volunteer Umpire, Away Team Manager etc.)*

First NameLast Name
Age Group
Division
Person's role at club*
Player Number
Other (If not listed)

Witness statement #1

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Yes, this person witnessed the incidentNo, they did not witness the incident
No Witness statement
Person's relation to club*
Person's relation to club (if not listed)
Player's jumper number *
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box*
YesNo

Witness statement #2

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Yes, this person witnessed the incidentNo, they did not witness the incident
No Witness statement
Person's relation to club
Person's relation to club (if not listed)
Player's jumper number
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box
YesNo

Witness statement #3

Enter the details of the first witness statement here. Witness statements on Word/Notes must be copied and pasted into this Jotform.
Yes, this person witnessed the incidentNo, they did not witness the incident
No Witness statement
Person's relation to club
Person's relation to club (if not listed)
Please enter witness statement in here. If you have received in as a Word Document, please copy and paste it into this box
Player's jumper number

Click to submit the form.

By submitting, you agree that you have filled out this form with true and accurate information and have not falsified or entered misleading information.
Should be Empty:

Details of Match