Witness Statement Form

Witness Statement Form

Please complete this form as fully and accurately as possible. Any information in this form may be used in disciplinary or any other proceedings. This includes the disclosure of this completed form to any participant charged in relation to the incident witnessed. If there is any information that you do not want to be disclosed please do not include it on this form.

If the incident contains any form of discrimination please also report via Kick it Out: https://www.kickitout.org/report

Report an incident to Nottinghamshire Police:

https://www.nottinghamshire.police.uk/do-it-online/report-online

Declaration

This statement is true to the best of my knowledge, information and belief. I understand that it may be given in evidence and used at any subsequent disciplinary proceedings. I am willing to attend a disciplinary hearing if required.

I confirm that this is true*

I would be happy to share and be contacted regarding this information by other partners*

We would like to share the information provided with agencies such as the Police to potentially take further action where appropriate. This would include sharing your full name and email address, provided on this form.

Yes

Your Details

Name*

Age (If U18)

Email Address*

Role*

Select or enter value

Your Club (If no Club links, write "N/A")*

Incident details

Date of Incident*

Time of incident (Approx)*

Venue*

Team(s) involved*

Person(s) Involved

Give the name(s) or a full description of any individuals involved to help with identification*

Please provide a detailed physical description of the offender(s) including shirt number if applicable, approx. age, height, build, hair/skin colour and any distinguishing features

Incident Witnessed

Describe exactly what happened in chronological (time) order*

This must only include what you saw or heard. Record any offensive language that you heard directly in speech marks (" ")

Where did it happen?*

Please provide specific details if possible, for example: on the spectator's touchline near the halfway line, just outside the centre circle.

Where were you at the time of the incident?*

Please confirm if your view was clear or blocked, how far you were from the incident, and include any adverse weather conditions

Was any action taken by the referee or anyone else?*

If so, what action was taken and by whom?

Did you report this to anyone?*

Please state who you reported this to (if anyone) and when

File Upload

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