Grassroots Reporting Form


You now have three options, in order to raise your concerns with us, they are as follows:


1: Tell us as much as you can about a specific incident so we can investigate and potentially raise a charge


2: Anonymously inform us of something so that we are aware of it, under the understanding that it would unlikely lead to a charge given the anonymity 


3: Inform us of something you're concerned about and that we can discuss with you further to establish next steps


a red Asterix indicates the essential information that we would require to take the matter forward, although we strongly encourage you to complete as much of the form a possible to assist us in our investigation.

This is the date you are making the complaint.

Please provide us with your full name (unless you wish to remain anonymous, see point 2.above)

Type of evidence*

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

Kick it Out*

Would you like to be contacted by the Kick It Out Grassroots team for additional support?

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Would you like to be contacted by the Kick It Out Grassroots team for additional support?*
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Your age*

Please confirm the age you were at the time of the incident.

Your current home address

Please provide these details so that we can contact you if we require further clarification.

Please provide these details so that we can contact you if we require further clarification.

Football Association Number if known

Select all that apply.

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Please state how you gender identify.

· Prefer to self-describe
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Do you consider yourself disabled?

This would be for information that relates to the complaint you are making.

Did this happen at a Match?

e.g. First, reserves, red, un 16 etc

e.g. First, reserves, red, un 16 etc

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Please state the venue which this incident took place. Include the pitch number if relevant.

Please indicate what the final score was in the match, alternatively if this match was abandoned, please state so, giving reasons as to why and the final score at the abandonment.

If you are not aware of the referee's name, please provide a description of them or provide information that would be helpful in order for us to identify them and make contact for a statement.

Did you or someone else report this to the Match Official and if so, when was this?

Did the referee take action?

The name of the person or the people that you allege has been discriminatory.

Did they have a shirt number or initials on their clothing?

If you are unable to provide name/s please provide us with a description. Approximate height, hair colour, hairstyle, what position they played in etc.

The name of the club they were 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 be descriptive with the time that the incident took place, even if that is just a particular point in the game that you recall.

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. If you don't have enough space there is an option to add files at the end of the form.

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 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 evidence, you will have the opportunity to do this and upload files at the end of the form, Including any photos or videos you wish to submit.

Police Involvement

Please indicate if yourself or others involved with this have involved the police with this complaint using the options below.

If the police have been notified, please state the force, Police Officer's details and any crime/ reference number they have supplied.

Desired outcome of complaint

Please indicate your desired outcome of this complaint, but please be aware that this cannot be guaranteed but we will discuss this with you.

we may decide what is appropriate from the information received and the evidence we have been provided. .

Name disclosure*

Please indicate if you are happy for your name to be disclosed in the event of a potential discipline charge. No contact details would be disclosed.

Attend a Personal Hearing?*

If a charge is raised, you maybe called to a personal hearing to confirm and clarify this evidence and answer questions, would you be willing to attend? They are normally held in the evenings during the weekdays where possible and typically using an online platform rather than in person.

Club aware of this complaint?

If you are part of a Club or League please state are they aware that you are submitting this complaint?

Should we require additional evidence, we will make contact with the witnesses that you detail below to ask them to submit a statement, please state: The full name, email address and phone number of those people you wish us to contact.

Confirmation of Evidence*

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

Please upload any additional files including statements you already have, or additional evidence such as photographs and videos,

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