UNITED STATES SOCCER FEDERATION

REFEREE REPORT

This report must be mailed within 48 hours after completion of game to proper authorities.

GAME:
	Home Team	Score	Visiting Team	Score

State Association/	Division/
Professional League	Age Group

Date of Game:	Scheduled time:
Field:	Actual kick off:
Address:	End of game:
	Score at half time:	- H V

REFEREE:	Grade:	SSN:	- -
Sr. Assistant:	Grade:	SSN:	- -
Jr. Assistant:	Grade:	SSN:	- -
4^th Official:	Grade:	SSN:	- -

Field Condition:		Weather:
Was the home team on the field on time?	If not, how late?		No. of Spectators: approx.
Was the visiting team on the field on time?	If not, how late?		Marking of field:
Players Passes of the home team received and checked.		Conduct of Officials:
Players Passes of the visiting team received and checked.		of Players:
Line-up of home team		of Spectators:
Line-up of visiting team		Dressing room for Referee:
4^th Official Game Log		for Players:

A supplementary form explaining circumstances must accompany any unusual situations.

Serious injuries during the game.

Name

Pass No.

Team

Nature of Injury

Players cautioned during the game.

Name

Pass No.

Team

Type of Misconduct

Players sent off the field—Player passes must be retained after the game and returned to proper authority with this report.

Name

Pass No.

Team

Type of Misconduct

I the referee fee of $ .

Referee Signature:

Phone #:

( ) -

Date:

For additional remarks use supplementary sheet.

For referee abuse/assault, severe injury, or other substantial occurrences, a photo copy must be sent to SRA

02/2001