Football Federation Tasmania Incident or Send off report

Please provide a detailed description of any incidents (state all facts, events and

circumstances of any such incident relating to the match even if it occurred before

or after the match or during half time).

This report must be submitted by Close of Business the day after the match.

Date and Time of Match *

Day Month Year Hour Minutes AM/PM Option

Venue

Incident Type *

Your Name *

First Name Last Name

Your Role *

Home Team *

Away Team *

Competition *

Name of Offender

First Name Last Name

Shirt Number of Player

Team Name

Time of Offence *

(e.g. 54' - use "00" if no specific time)

Send Off Offence

R1 - Is guilty of serious foul play R2 - Is guilty of violent conduct R3 - Spits at an opponent or any other person R4 - Denies the opposing team a goal or an obvious goal scoring opportunity by deliberately handling the ball R5 - Denies an obvious goal scoring opportunity to an opponent moving towards the players goal by an offense punishable by a free-kick or a penalty kick R6 - Uses offensive or insulting or abusive language and/or gestures R7 - Receives a second caution in the same match Not applicable

Please describe all relevant facts related to the incident

By clicking on the "submit" button you acknowledge and agree that:

(i) you are the match official whose name and email address are entered above; and

(ii) the above report is an accurate description of the incident (or incidents) that you witnessed.

Further, you grant FFT with approval to contact you for further information or additional reports as required.

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