2 / Date of birth -
3 / Contact number (if U18 please provide parent/carer number and consent) -
4 / FA FAN number -
5 / RA membership number -
6 / County FA & LRA -
7 / Referee level -
8 / Do you have any registered disabilities? - If yes, please provide details -
9 / Date and time of assault -
10 / Address where assault occurred -
11 / Type of assault (physical/verbal) -
12 / Details of assault (what was said/happened) -
13 / Have photos been taken of your physical injuries? -
14 / Did you attend Hospital/Doctor? If yes, please provide names of consultants & treatment details -
15 / Have the Police been contacted? If yes, please provide name, collar number of officer & incident number -
16 / Have you completed a Police Victim Impact Statement?
17 / Have the Police discussed and offered you Victim Support? -
18 / Were there any witnesses? If yes, please provide names and contact details -
19 / Is there CCTV/Smart Phone evidence available? - If yes, please provide details -
20 / Has the County FA Welfare Officer been contacted? If yes, please provide their name and support offered -
21 / Has the County RDO been contacted? If yes, please provide their name and support offered -
22 / Has the assault resulted in time off work/school/college? -
23 / Have the Insurance company been contacted – 0800 254 5404? If yes, please provide name and support offered -
24 / Has the CRA/LRA been contacted? If yes, please provide name and support offered -
25 / Do you require help and support from the RA? If yes, please provide reasons -
26 / Do you require help and support completing your match report? -
27 / Name of Team/s -
28 / Competition -
29 / Name of individual(s) committing assault if known -
30 / Was the game abandoned? –
Please add any additional details:
On completion of all sections please return to:
Jan 2018
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