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.

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*

If relevant we would like to share the information provided with our Inclusion Advisory Group for further support, the University of Leicester for research or other agencies.

Yes

Your details

Name*

Age (If U18)*

If you are under the age of 18 - you may want to complete this form instead

Email address*

Role*

Select or enter value

Club (If applicable)*

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

Did anybody else witness this incident?

Please give us names, the club they represent, the role they had on the day and contact details if known

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

In your opinion, what is a reasonable outcome of this allegation?*

Please be aware that it is at the County FA's discretion as to what action is taken, but we will inform you of the outcome.

Select

File Upload

If you have any other documentation / photos please upload them here

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse