Date of Match

MM

DD

YYYY

First Half/Second Half

First Half

Second Half

Reported by Name

First Name

Last Name

Ground Manager Name

First Name

Last Name

Name of Accused

First Name

Last Name

Name of Other Player/ Person Involved

First Name

Last Name

Type of Offence

(If there is more than 1 relevant offense include offense number in incident description)

Use offensive or obscene language to any participant.

Enter the Field of Play or the Playing Area during the course of a match without the prior approval of the Ground Manager appointed by the home Club and/​or League.

Excessively dispute the decision of a Referee or Touch Judge either during or after a match.

Assault, or act with aggression, to any person/​s

Behave in a way contrary to the Code of Conduct and/​or the spirit of the game

Act in such a way as to exhibit racial intolerance, by language or other conduct, to any person/​s

Refuse to accept the reasonable direction of the Ground Manager, official of the team/​ Club which that person is supporting, or official of the home Club and/​or League.

I recommend this charge be graded as

Low

Medium

High

Serious

Agree to Provide Evidence *

By submitting this online Incident form, I understand and agree by selecting Yes or No below, that I may be required to provide evidence at a NSWRL Regional Group Judiciary Tribunal.

Yes

No