Discipline Reporting Form
For Submitting Red & Yellow Card Reports by Referee, or when Applicable, Assistant Referees
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Email *
Offending Player's First Name *
Offending Player's Last Name *
Offending Players CIPP#
team should provide off of the match roster
Offending Player's Number *
add in position played, if possible
Offending Player's Team *
Competition Type *
Date of Match *
League Division *
Home Team *
Visiting Team *
Match Result *
Home Team Score
Match Result *
Visiting Team Score
Venue *
Host Venue/Host Team
Offending Player's Union *
If collegiate conference, or outside the Midwest, enter that in "other"
Clear selection
Action Taken *
When Did The Incident Happen? *
Time Elapsed In Period When Incident Occurred *
Was The Incident Reported By An Assistant Referee? *
If "Yes", enter AR's name in "Other" field.  AR must submit version of this form as well
Select All Applicable Laws *
Required
Description Of Incident *
On a scale of 1-10, with 10 being most severe, please rate the level of severity of the infraction, in your opinion
Include for both red and yellow cards
Clear selection
Referee Name *
Assistant Referee Name, if applicable
Referee Society *
Local or Territorial
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