SUFFOLK COUNTY FOOTBALL OFFICIALS ASSOCIATION - (Smithtown, NY)

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OFFICIALS GAME LIABILITY REPORT (INJURY)

NYSACFO, INC

* Date of Contest:

* Site of Contest:

* Name of Injured Official:

* Injured Official Position:

* Injured Official Removed From Rest of Game?:

* Type of Injury:

* How Did The Injury Occur? Try to be specific.:

* Official Transported To Hospital?:

* Home School:

* Visiting School:

* Game Level:

VARSITY

JV/9

JHS

YOUTH

* Weather Conditions:

* Field Condition:

* Any Replacement Officials?:

If YES, Name of Replacement(s):

If you are JV or JHS official and officiated a JV or JHS game and were the White Hat put your name here:

Name of Officials - JV / JHS / YOUTH LEAGUES:

COMPLETE THIS FORM WITHIN 72 HOURS AFTER A GAME IN THE EVENT OF AN INJURY!Liability Reports be submitted for any injury that an official deems serious that has the potential of resulting in a claim.

SUFFOLK CHAPTER

* DATE OF REPORT:

* indicates required fields