U.S. FIGURE SKATING

REFEREE'S REPORT — NONQUALIFYING COMPETITIONS

TO: U.S. Figure Skating Headquarters (attn: Director of Technical Services)

Singles, Pairs and Dance Competitions: Regional Vice Chair, Competitions Committee

Synchronized Skating Competitions: Sectional Synchronized Skating Vice Chair, Competitions Committee

Following is the Referee's Report covering the following competition:

NAME OF COMPETITION:
PLACE: / DATES:
Please print your name:
Signature: / Date Signed:

1.Did this competition have Solo Dance Series Events? Yes No

2.Did this competition have Showcase/Artistic Events? Yes No

ITEMS TO BE SUBMITTED

1.Officials’ assignment sheet (Form 104) [rule 2204].

2.A record of the initial and final placements in each event [rule 2204]

(This can be a marked copy of the competition program, copies of signed Hal2 computer component/cumulative results (or signed copies of Forms 105/105x), or a computer generated summary of placements).

GENERAL

1.Any deviations from or comments on the following [rule 2204]

[a]Rules governing competitions:

[b]The official schedule

[c]Proper conduct of judges/officials

2.Any adverse comments or particularly favorable comments on [rule 2204]

[a]Rink conditions

[b]Housing

[c]Transportation

[d]Music

[e]Mini System / IJS Equipment

3.Any protests, accidents, or unusual happenings [rule 2204]

USE ADDITIONAL SHEETS IF NECESSARY

U.S. Figure Skating

Referee Report

List of Judges to Receive CEU Credit

List of Technical Panel Officials to Receive Activity

General Instructions:Please provide the officials’ full names (first and last) as they appear in the U.S. Figure Skating Directory (no nicknames, and please do not just list the first initial and the last name). Membership numbers are also available in the U.S. Figure Skating Directory and are greatly appreciated. The more detail that you provide, the better chance we have of giving the CEU credit/activity to the correct officials.

Name of Competition: / Sanction #:
Referee Name: / Competition Dates:

Below, please list the names of all officials who should receive CEUs for serving as a Judge and/or Referee at this competition. For CEU guidelines, please visit

Judges & Referees
First & Last Name / U.S. Figure Skating # / Discipline(s) for Credit+
Place an x in the appropriate column(s)
S&P / Dance / SYS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

+Disciplines:S&P = Singles & PairsDance = Ice DanceSYS = Synchronized Skating

USE ADDITIONAL SHEETS IF NECESSARY
U.S. Figure Skating

Referee Report

List of Judges to Receive CEU Credit for this Competition

List of Technical Panel Officials to Receive Credit for Activity

Below, please list the names of all officials who should receive activity for serving as a Technical Controller, Technical Specialist, Data Operator and/or Video Replay Operator at this competition. If an official served on a technical panel for more than one discipline, please list that person for each discipline served.

Technical Panel - SINGLES
First & Last Name / U.S. Figure Skating # / Role*(Place an x in the appropriate column(s))
TC / TS / Data / Video
1
2
3
4
5
6
7
8
9
10
Technical Panel - PAIRS
First & Last Name / U.S. Figure Skating # / Role* (Place an x in the appropriate column(s))
TC / TS / Data / Video
1
2
3
4
5
Technical Panel - DANCE
First & Last Name / U.S. Figure Skating # / Role* (Place an x in the appropriate column(s))
TC / TS / Data / Video
1
2
3
4
5
Technical Panel - SYNCHRONIZED
First & Last Name / U.S. Figure Skating # / Role* (Place an x in the appropriate column(s))
TC / TS / Data / Video
1
2
3
4
5

*Role:TC = ControllerTS = Specialist or AssistantData = Data OperatorVideo = Video Replay Operator

USE ADDITIONAL SHEETS IF NECESSARY

#64-B (Rev 1/12)U.S. Figure Skating, 20 First Street, Colorado Springs, CO 80906  Fax: 719.635.9548  E-mail: