Incident Report Form

This form is required to be completed and submitted no later than 48 hours from the time of incident

Name of Competition

Full Name of the Person Reporting

Role

Umpire

Captain

Volunteer

Other

Please specify if others ?

Team of Person Reporting

Which round of the competition did this incident happen?

Email:

Phone

Name of Person Reported

Team against which this incident is being reported

Home Team

Away Team

Venue/Match Location:

Date of the Incident:

Time of the Incident:

Umpire Name

Was the Player Reported or team notified that this Report would be made ?

Yes

No

What offence is to be applied?

What offence is to applied? (Use the article numbers from the NPL Code of Conduct)

Offences table

levels Code of Conduct

Level 1

Level 2

Level 3

Level 4

CNSW-Code-of-Conduct Offences

Please refer to the Code of Conduct offences.

Description of the incident

Description of the Incident:

Please provide a detailed Report of what you saw, heard or witnessed that is relevant to this Report. Please don't interpret the offence and/or applicable sanction. Simply state the facts, context and any other relevant facts that you deem necessary.

Was the game live-streamed?

Yes

No

Evidence

Upload file

Free Text

Acknowledgment of Privacy Policy

Acknowledgement

I acknowledge that I have read and agree to the NPL Privacy Policy.

Free Text

Declaration by Person Reporting

New Field:

By making this Report, you declare that the information contained within this Report is true and correct to the best of your knowledge and that you have not provided any false or misleading information as part of this Report. You further acknowledge that it is an offence under the Complaints and Dispute Resolution Policy to provide false or misleading information as part of any investigation into a breach of the Code of Conduct

Free Text

Signature of the reporting person:

New Field:

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