Umpiring WA Metropolitan & Country Competitions

Please note: If this matter is urgent or requires immediate assistance - please call Emergency Services on 000 or Crimestoppers on 1800 333 000

This WA Football Integrity Report Form covers matters relating to the following categories.

• Child Safe Guarding
• Grooming
• Sexual Misconduct
• Illicit Substances
• Wagering
• Anti Doping
• Match Fixing

By completing and submitting the following information the WA Football Integrity Unit will be notified and contact you accordingly.

Please indicate if you wish to remain anonymous to parties external to the WA Football Integrity Unit. (However please remember if you do not leave your name, we will be unable to contact you for further information).

Please indicate if you wish to remain anonymous to parties external to the WA Football Integrity Unit. (However please remember if you do not leave your name, we will be unable to contact you for further information). Yes No
Are you under the age of 18?

Are you under the age of 18? Yes No
Please Enter Your Details
Your Name Your Name First Last
Your Role
Your Phone Number
Your Email
What is the nature of the Incident

What is the nature of the Incident Child Safe Guarding Grooming Sexual Misconduct Illicit Substances Wagering Match Fixing Anti Doping Other

Please select all responses that apply.
Who does the Incident involve

Who does the Incident involve Player Umpire Club Official Coach Umpire Coach League Official Parent Trainer Spectator WA Football Staff Umpire Assoc Official

Please select all responses that apply.
Which League or Umpire Association does the Incident relate to
Date of Incident
Time
At what location did this Incident occur
Match Details

Name of team/s involved
Brief Description of Incident

Please provide a brief summary of the incident.
Has the matter been reported to the Police

Has the matter been reported to the Police Yes No Unsure

Has the incident been Reported to Police
If YES please provide the Offence Report Number or where reported.
Upload a File or supporting document if relevant

Attach Files

A supporting file or photograph may be attached.
The information I have provided in this Statement is true and correct to the best of my knowledge and represents everything I can recall. I understand that this Statement may be used to assist the WA Football Integrity Unit report on how a matter may proceed and that it may be provided to other relevant parties.

By submitting this form I acknowledge the above statement

Umpiring WA Metropolitan & Country Competitions

Umpiring WA Metropolitan & Country Competitions

Please Enter Your Details