Reporting Discrimination Form

Full Name*

Email Address*

Contact Telephone Number*

What role were you occupying at the time of the incident?*

Select

What form of discrimination are you reporting*

Select

Date the incident took place*

Specifically where did the incident take place?*

Please provide the location of where the alleged incident took place: Ground name or postcode

What was happening when the alleged incident took*

Football Match

Football Training

Other

Details of the environment where the incident took place*

Please provide details of Age Group, Clubs Involved, Competition (league name). If you selected OTHER above, please provide a brief description of the environment (social event, fundraiser)

The Alleged Incident

This section provides the details of the alleged incident. Please be as specific and as factual as you can be. This includes detailing the EXACT words/gestures used.

What actually happened?*

What EXACT words/gestures were used?*

Who used the words or gestures (the offender)*

When did the incident happen?*

Did the incident happen pre-match, during the match or post match? If the incident took place somewhere other than a football match, please provide details when during the event the incident happened.

Your Statement

Did you personally witness the incident?

Yes

No

How far away were you from the incident when it happened?*

Did anyone else witness the incident?

Do you have contact details for the witnesses*

Witness statements are vital when compiling credible evidence in support of the case. We will request these details from you as part of the investigation.

Not personally but I know where to get them

No I don't and I don't know where to get them

Yes I do

Was the incident reported to anyone in charge (i.e*

Yes it was reported to a member in charge

Yes the incident was reported to the Match Official

No the incident was not reported

Please provide the name of the Member In Charge if known

The Member In Charge could be the Match Official or another individual who was in control of the event on the day

The Investigation

Thank you for reporting the alleged incident. Your statement provides credible evidence to begin the investigation.

Are you happy for your statement to be disclosed to the opposition/ offender?*

Select or enter value

Would you be willing to attend a hearing to provide verbal evidence if required?*

Select or enter value

Anything else we need to know

Please use this section to provide any further details of the alleged incident.

File Attachments

Please use this section to upload any supporting documentation (images, videos, documents, print screens)

Drag and drop files here or

Send me a copy of my responses