Referee's Game Report
Part I: Instructions
1. This form will be used by USA Hockey game officials to document all game-related incidents that result in the assessment of one or more game-suspending penalties to one or more players, except for suspensions resulting from violations of Rule 404(d) (Excess Penalties) .
2. Use a single form to record all penalties assessed during a single stoppage in play. These include minor or misconduct penalties that lead up to or otherwise relate to the game-suspending penalties. Use a separate form for each separate incident (stoppage of play).
3. The Referee (in the one referee-two linesmen system) or the Senior Referee (in the two-referee system) is responsible for completing all game reports.
4. Completed game reports must be received by the local USA Hockey Supervisor of Officials, or other designated authority, within 48 hours of each incident, except for reports involving physical assault on a game official, which must be received within 24 hours.
Part II: Assigned Officials / Part III: Game Information
Referee (1 Ref/2 lines) /
Name
/Telephone
/League
Duluth Mens League /Date
5/29/09 /Level
AAReferee/Linesman
/Name
Rich Tyson /Telephone
678-231-1936 /Home Team
Wild Bills /Visiting Team
Break Away GrillReferee/Linesman
/Name
Michael Cap /Telephone
/Location
Duluth /Start Time
10:20PM /Final Score
Home
8 /Visitors
8Part IV: Penalty Summary
Pd / Time / Team / No. / Player Name / Penalty Assessed / Mins / Rule Ref.
3 / 5:00 / Home / 7 / Tim Palmer (Wild Bills) / Hooking / 2:00 / 619 (a)
3 / 5:00 / Home / 7 / Tim Palmer / Fighting / 5:00 / 613 (a)
3 / 5:00 / Home / 7 / Tim Palmer / Game Misconduct (fighting) / 10:00 / 613 (e)
3 / 5:00 / Visitor / 71 / Eric Belafonte (Break Away Grill) / Fighting / 5:00 / 613 (a)
3 / 5:00 / Visitor / 71 / Eric Belafonte / Game Misconduct (fighting) / 10:00 / 613 (e)
3 / 4:30 / Home / 49 / Dan Wheelin (Wild Bills) / Delay of Game / 2:00 / 609 (e)
3 / 4:30 / Home / 49 / Dan Wheelin / Misconduct / 10:00 / 601 (d)
3 / 4:30 / Home / 49 / Dan Wheelin / Game Misconduct / 10:00 / 601 (f,1)
Part V: Narrative Description
Briefly describe the entire incident. Include sufficient detail to enable league authorities to determine if additional action is needed. Include the who, what, when, where, how, and why in your description. Identify aggressor(s) where possible. Use reverse side for diagrams or to continue remarks.
At 5:00 of the third period:
# 7 – Time Palmer (Wild Bills) hooked # 71 Eric Belafonte (Break Away Grill ) in front of the net. Palmer then proceeded to grab Belafonte in the face area and removed his helmet as they fell to the ice. Both players were throwing punches on the ice and had to be separated by the officials.
At 4:30 of the third period:
# 49 Dan Wheelin (Wild Bills) continued to trap the puck with his skate along the boards in his defending zone between the top of the face off circles and the blue line. The attacking team was on a power play and on several occations used their sticks to free the puck. Several times the puck was freed as I yelled “move the puck” at which time on each occation Wheelin would once again trap the puck with his skate to the boards while the other team was trying to free the puck. I then yelled “black move the puck” the third time this had happened he had the puck trapped to the boards with his skate alone and other sticks were attempting to dig the puck out. I then blew the whistle and assessed a delay of game penalty. At this time Wheelin yelled “ are you fucking kidding me?” (Misconduct assessed) and then yelled “you’re a fucking douchbag” (game misconduct assessed).
DATE / PRINTED NAME OF PERSON SUBMITTING REPORT / SIGNATURE