Hertfordshire County FA -Witness Statement Form

Hertfordshire County FA -

Witness Statement Form

Please complete this form as fully and accurately as possible. Any information included in this Statement may be used in disciplinary or any other proceedings. This includes the disclosure of this Statement to any Participant charged in relation to the incident and to which this Statement relates.

If you require any additional space continue on a separate sheet and indicate which question in your Statement the additional sheet relates.

Your Name:*

Your Age*

Under 18

18 and Above

Parent Name

Please include the name of the parent that has assisted in the completion of this form.

Email Address*

We may need to contact you to request further information, please include your email so that we can do so.

Your Role*

Select or enter value

Club

[if applicable]

Select or enter value

Match Details

If the report is not in relation to a match, please enter the name of the club/individual you are providing a statement about, and enter the date of the offence in the Date of Match space.

Date of Match*

Home Team*

Select or enter value

Home Age*

Select or enter value

Home Variant

This is for where clubs have multiple teams at an age group, for instance, your team may be "Blues", "North", "Juniors" etc. If you are unsure, please check with your manager.

Away Team*

Select or enter value

Away Age*

Select or enter value

Away Variant

This is for where clubs have multiple teams at an age group, for instance, your team may be "Blues", "North", "Juniors" etc. If you are unsure, please check with your manager.

Competition

[if applicable]

Incident Details

What would you like to report?*

Describe to the best of your recollection what happened in time order. This must only include what you saw and/or heard. Record any language that you heard in speech marks [“ ”]. Please do not censor any words, we need the exact words used.

Please also identify the offender, this can either be by their name, shirt number, or a physical description.

Please keep this concise and relevant to the main incident.

When did it happen?

E.g. prior to the kick-off, 30 minutes in to the first half:

Where did it happen and where were you?

Was any action taken by the Referee or anyone else

If yes, what action was taken and by whom?

Did you report the incident to anyone?

If yes, who did you report it to and when?

Please include here any other information that may assist the investigation:

By submitting this Witness Statement, you agree that the information provided is factual and accurate to the best of your knowledge, information and belief.

If you are under 18, your name will be redacted in line with our Safeguarding procedures.

I understand that my statement will be used as evidence towards any charges that may be raised, and as a result my name will be included within the case pack*

Hearing

Are you willing to attend a disciplinary hearing if required?

Yes

true

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