Your role
*
Referee
Assistant Referee
Parent or Guardian of Referee
Other Tournament or Competition Official
Coach
Player
Spectator or Parent
Other not listed
Email
*
*
First Name
Last Name
Your Date of Birth
*
This information is used to determine: (1) if a possible SafeSport violation exists, and/or (2) to ensure proper action is taken in accordance with HSRC and USSoccer Policies and Procedures, as applicable.
MM
DD
YYYY
Phone
(###)
###
####
Game Date
*
MM
DD
YYYY
Game Time
*
Hour
Minute
Second
AM
PM
Game Site (Complex / Park)
*
Game Field Number
*
Person(s) mistreating or abusing referee(s)
*
Coach
Parent or Spectator
Player
Other team official
Other not listed
Which team is the person(s) being reported associated with?
*
Home team
Visiting team
Neither
Unknown
Is the person(s) mistreating or abusing referees an adult, or appear to be an adult?
*
Yes
No
Not sure
s the referee(s) being mistreated or abused a minor (under 18), or appear to be a minor?
*
Yes
No
Do you have possession of or access to video or other supporting media?
*
Yes
No
Did the abuse include verbal abuse?
*
Yes
No
Report Narrative
*
REPORT NARRATIVE INSTRUCTIONS
In the space below, please provide a BRIEF but detailed description of the incident . BE BRIEF BUT AS SPECIFIC AS POSSIBLE.
Enter exact words or phrases spoken, including profanity. Enter exact actions or gestures, if applicable. Enter exact physical contact, if applicable.
Provide all FACTS that are applicable. Details of referee decision and/or its accuracy are not required.
Please avoid commentary, background information, or opinion.
Were you on the referee crew for this game?
*
Yes
No
