Clone of Disciplinary Incident/Ejection Report Form

Disciplinary Incident/Ejection Report Form

The official(s) must submit this report within 24 hours of the game. Submit a separate report for EACH ejected person and, as applicable, for each separate incident. Describe only that person’s incident. If more than one person was ejected, complete one form for each person. If a spectator’s name is unknown, enter UNKNOWN.
1. NSBO Area Where the Incident Occurred:
2. Jurisdiction Incident Occurred
4. Type of Game (Event)
Ejected Person Name (If the person's name is unknown, enter UNKNOWN)

First NameLast Name
Ejected Person Club/Team
Date of Game

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Scheduled Start Time

Hour Minutes

AM/PM Option
Approximate Time of Incident (within the game)
Example: Last minute of the fourth quarter
5. Name of Reporting Referee

First NameLast Name
6. Phone Number
Format: (000) 000-0000.
7. Email
example@example.com
8. Name of Official #2

First NameLast Name
9. Name of Official #3

First NameLast Name
10. Facility/gym location the incident occurred:
12. Gender of Group(s) involved:
13. Age group of athletes:
14. Team A Name:
15. Team B Name:
Role of the ejected person (select one)
How was this person ejected? (select one)

Other
Incident details (Please describe the incident in factual detail not already included above. Please DO NOT include any opinions or recommendations on consequences.)
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