Discrimination Complaint

Please specify the date of this complaint

Please give us your full name, you will get the opportunity later to tell us if you wish this to be disclosed to the complainant later.

Please complete your address details including postcode.

We may need to contact you in relation to this complaint so please let us know your best contact phone number.

Please also let us have your email for contact purposes.

If known please state your Football Association Number or NPD number.

Please state any other relevant information.

At the time of submitting this complaint are you over 18 years of age?

Please let us know of any football roles you hold in football.

If you are not in a football role please state if you are a spectator, parent, member of the public.

Please list all the current clubs and teams you have been and are associated with.

Please state all the club that the victim is currently associated with.

Please state all the League the victim is currently registered with.

Please state all the roles that the victim holds within your club and what role they held on the day of the alleged incident.

If there is more than one victim and you haven't been able to complete them all above please state yes below and use the upload file section at the end of the form to specify the other victims details.

Please state the date of the alleged incident.

Please state the Away club on the date of the alleged incident.

Please state the home club TEAM name. This could just be the age group they play in.

Please state the home club on the date of the alleged incident.

Please state the home club TEAM name. This could just be the age group they play in.

If known please indicate what type of fixture this was.

Please state if known what League or Competition this took place in.

If known what time did the match commence.

Where did the incident take place, if possible please give the address and postcode.

If known what was the final score with the home team score first.

If known please let us know the full name of the Match Official on the day.

Please state if and at what time did you make the Match Official aware of this allegation. If this wasn't possible please state the reasons why.

Please state any action that the Match Official took in relation to this alleged incident.

If you are not aware of the referees name, please provide a description of them or provide information that would be helpful in order for us to identify them.

Please state the full names of the perpetrator/s.

Please state the shirt numbers/position or roles they held on the day.

It would be useful for us to have a description of the alleged perpetrator/s to ensure that there isn't any mis-identification during the process.

What Club was the alleged perpetrator/s associated with?

Please state if the perpetrator or their club are aware of this complaint and if so how they have been made aware of it.

Please state on what grounds you are alleging an aggravated breach has taken place. Disability Ethnic Origin Gender Gender reassignment Sexual Orientation Religion or belief Colour Race Nationality If you have believe you have been victimised as defined in the Equality Act 2010 please specify one or more of the above grounds or from the list below. Pregnancy Maternity Marital status Civil Partnership

Please indicate from the options below what type of evidence this statement is.

Please be descriptive with the time that the incident took place, even if that is just a particular point in the game.

In order for us to get an indication of where you were positioned, in relation to the alleged incident please give us some details of where you were and where the incident took place.

Please also state what distance you would say was between you and the incident and if you had an unobstructed view of the incident.

Please state if their is any previous history between the parties that we may need to be aware of.

Please give us the full details of the complaint you wish to make, please be as descriptive and factual as you can. If there was any foul language used please write this in full and don't star out any letters or words. If you don't have enough space or wish to add further supporting statements or photo evidence you will have the opportunity to do this and upload files at the end of the form.

Please indicate if the Police are involved with this complaint using the options below.

If the police are involved please state which constabulary is currently dealing with this, along with any Crime or Log numbers, the current status of the police complaint and Police Officer details you have been given.

Please indicate if you have or intend to report this complaint to Kick It Out.

We currently have a partnership with Lancashire Victim Services who could offer you some emotional support for free. If you would like us to put them in touch with you please indicate. This would not mean that you have to report the matter to the police.

Please indicate your desired outcome of this complaint.

Are you happy for us to disclose your name to the alleged offender in respect of this complaint and use this as a statement to support any charges that maybe issued.

If a charge is issued by the discipline department, the alleged perpetrators would get the option to plead not guilty and attend a personal hearing, at the hearing they are entitled to question the evidence upon which the charge is based. Would you be happy to attend this hearing and answer any questions they or the discipline panel may have in a controlled environment?

If you are not the Club Secretary, please can you indicate if you have made them aware of this complaint and that you are submitting this to ourselves for consideration.

Please list the full names and email addresses of any other witnesses that are happy for us to contact them in relation to this complaint.

Please confirm that this statement has been submitted and is in the words of the person named as the witness.

Please upload any supporting evidence such as photos/videos, additional witness statements.