Referee Report
This report must be mailed within 24 hours after completion of game to proper authorities
Game
/ 0123456789101112131415 / vs / 0123456789101112131415Home Team / Score / Visiting Team / Score
Competition / District LeagueState LeagueState CupOpen Cup /
Division
/ IIIIIIIVV /Age Group
/ U8U9U10U11U12U13U14U15U16U17U18U19 / Boys / GirlsDate of Game / Scheduled Time / am / pm
Field and Address / Actual Kickoff / am / pm
End of Game / am / pm
Score at Halftime / home / 0123456789101112131415 / vs / away / 0123456789101112131415
Referee / Grade / 87654
Assistant Referee 1 / Grade / 87654
Assistant Referee 2 / Grade / 87654
Weather / Field Conditions
No. of Spectators / approx. / Field Markings / Good / Fair / Poor
Player Passes / Line-up
of the home team / were / were not / received and checked / of the home team / is / is not / enclosed, available
of the visiting team / were / were not / received and checked / of the visiting team / is / is not / enclosed, available
A Supplementary Referee Report must accompany the Referee Report explaining circumstances in any unusual situations.
Serious injuries during the game:
Name / Pass # / Team / Nature of Injury
Name / Pass # / Team / Nature of Injury
Players cautioned during the game:
Unsporting Behavior (UB)Dissent (DT)Persistant Infringement (PI)Delays Restart of Play (DR)Fails to Respect Distance (FRD)Enters Without Permission (E)Leaves Without Permission (L)
Name / Pass # / Team / Type of Misconduct
Unsporting Behavior (UB)Dissent (DT)Persistant Infringement (PI)Delays Restart of Play (DR)Fails to Respect Distance (FRD)Enters Without Permission (E)Leaves Without Permission (L)
Name / Pass # / Team / Type of Misconduct
Unsporting Behavior (UB)Dissent (DT)Persistant Infringement (PI)Delays Restart of Play (DR)Fails to Respect Distance (FRD)Enters Without Permission (E)Leaves Without Permission (L)
Name / Pass # / Team / Type of Misconduct
Unsporting Behavior (UB)Dissent (DT)Persistant Infringement (PI)Delays Restart of Play (DR)Fails to Respect Distance (FRD)Enters Without Permission (E)Leaves Without Permission (L)
Name / Pass # / Team / Type of Misconduct
Unsporting Behavior (UB)Dissent (DT)Persistant Infringement (PI)Delays Restart of Play (DR)Fails to Respect Distance (FRD)Enters Without Permission (E)Leaves Without Permission (L)
Name / Pass # / Team / Type of Misconduct
Players sent off the field: (Player passes must be retained after the game and returned to the proper authority with this report.)
Serious Foul Play (SFP)Violent Conduct (VC)Denies Goal - Handling (DGH)Denies Goal - Foul (DGF)Abusive Language (AL)Second Caution (2CT)Spits at any Person (S)
Name / Pass # / Team / Type of Misconduct
Serious Foul Play (SFP)Violent Conduct (VC)Denies Goal - Handling (DGH)Denies Goal - Foul (DGF)Abusive Language (AL)Second Caution (2CT)Spits at any Person (S)
Name / Pass # / Team / Type of Misconduct
Serious Foul Play (SFP)Violent Conduct (VC)Denies Goal - Handling (DGH)Denies Goal - Foul (DGF)Abusive Language (AL)Second Caution (2CT)Spits at any Person (S)
Name / Pass # / Team / Type of Misconduct
Referee Signature
/Phone #
/ (203)(860) /Date
For State League or Cup gamesmail or fax completed reports to: / CJSA Office
11 Executive Drive
Fanmington, Ct.06032
Phone 860-676-1161
Fax 860-676-1162 / For District League games mail or fax completed reports to your District Administrator. All “sendoffs” must be reported to the CJSA Office.
In case of Referee Assault or Referee Abuse notify the CJSA president immediately.
/ United states soccer federationSupplementary Referee Report
This report must be mailed within 48 hours after completion of game to proper authorities.
Game / vs
Home Team / Score / Visiting Team / Score
State Association / / Division /
Professional League / Age Group
Date of Game /
Referee
Describe Any Unusual Incident: /XAD XAD XAD
XAD XAD XAD XAD
XAD XAD XAD XAD
XAD XAD XAD XAD
XAD XAD XAD XAD
goal
Remarks:
Referee Signature
/ID #
Phone # / (203)(860) /Report Date
CJSA Referee Report + Supplementary Report .doc