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SUFFOLK COUNTY FOOTBALL OFFICIALS ASSOCIATION
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PLAYER GAME LIABILITY REPORT (INJURY)
*
SPORT (CHOOSE ONE):
BOYS FOOTBALL
GIRLS FLAG FOOTBALL
*
Date of Contest:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
*
Site of Contest:
*
Name and Number of Injured Player:
*
Injured Players School?:
Select Home Team
Amityville
Babylon
Bay Shore
BayPort Blue Point
Bellport
Brentwood
Center Moriches
Centereach
Central Islip
Commack
Comsewogue
Connetquot
Copiague
Deer Park
East Hampton
East Islip
Eastport South Manor
Elwood John Glenn
Greenport
Hampton Bays
Harborfields
Hauppaugue
Half Hallow Hills East
Half Hallow Hills West
Huntington
Islip
Kings Park
Lindenhurst
Longwood
Mcann-Mercy
Miller Place
Mount Sinai
Newfield
North Babylon
Northport
Pat-Med
Port Jefferson
Riverhead
Rocky Point
Sachem East
Sachem North
Sayville
Shoreham Wading River
Smithtown East
Smithtown West
South Hampton
Walt Whitman
Ward Melville
West Babylon
West Islip
Westhampton Beach
William Floyd
Wyandanch
*
Injured Player Removed From Rest of Game?:
Select Yes or No
Yes
No
*
Player Transported To Hospital?:
Select Yes or No
No
Yes - By Ambulance
Yes - By Parent or other person
*
Home School:
Select One
Amityville
Babylon
Bay Shore
BayPort Blue Point
Bellport
Brentwood
Center Moriches
Centereach
Central Islip
Commack
Comsewogue
Connetquot
Copiague
Deer Park
East Hampton
East Islip
Eastport South Manor
Elwood John Glenn
Greenport
Hampton Bays
Harborfields
Hauppaugue
Half Hallow Hills East
Half Hallow Hills West
Huntington
Islip
Kings Park
Lindenhurst
Longwood
Mcann-Mercy
Miller Place
Mount Sinai
Newfield
North Babylon
Northport
Pat-Med
Port Jefferson
Riverhead
Rocky Point
Sachem East
Sachem North
Sayville
Shoreham Wading River
Smithtown East
Smithtown West
South Hampton
Walt Whitman
Ward Melville
West Babylon
West Islip
Westhampton Beach
William Floyd
Wyandanch
*
Visiting School:
Select One
Amityville
Babylon
Bay Shore
BayPort Blue Point
Bellport
Brentwood
Center Moriches
Centereach
Central Islip
Commack
Comsewogue
Connetquot
Copiague
Deer Park
East Hampton
East Islip
Eastport South Manor
Elwood John Glenn
Greenport
Hampton Bays
Harborfields
Hauppaugue
Half Hallow Hills East
Half Hallow Hills West
Huntington
Islip
Kings Park
Lindenhurst
Longwood
Mcann-Mercy
Miller Place
Mount Sinai
Newfield
North Babylon
Northport
Pat-Med
Port Jefferson
Riverhead
Rocky Point
Sachem East
Sachem North
Sayville
Shoreham Wading River
Smithtown East
Smithtown West
South Hampton
Walt Whitman
Ward Melville
West Babylon
West Islip
Westhampton Beach
William Floyd
Wyandanch
*
Game Level:
VARSITY
JV
JV/9
JHS
YOUTH
*
Weather Conditions:
SELECT ONE:
Clear
Clear/Hot
Slight Rain
Heavy Rain
Snow
GIRLS FLAG FOOTBALL - ONLY
Head Referee:
Line Judge:
Back Judge:
FOOTBALL (REGULAR) - ONLY
VARSITY WHITE HAT:
SELECT ONE:
Kyle Coyne
John Dammer
Steve Gallo
Charles Groh
Mickey Kane
Bob Komoroski
Tony McQuade
Tom Maiger
Tony Melito
Marc Negrin Sr
Jeff Nelson
Tim O'Neill
Roger Padula
Mike Stein
Carl Superina
Tom Wodzenski Jr
Kevin Wolford
VARSITY UMPIRE:
SELECT ONE:
Matt Bertsch
Gerry Butts
Kevin Chilton
Kevin Conlon
Richard Freund
Adam Gorden
Dave Hohf
Aaron James
Ron LaSerra
Marc Negrin Jr
Matt O'Brien
George O'Hanlon
Tim O'Neill
John Palmero
Gary Wojtas
VARSITY LINESMAN:
SELECT ONE:
Dan Bevilaqua
Don Bonacorsa
Steve Chilton
Tom Coyne
Dave Frabizio
Joe Giuliantano
Jordan Grant
Tod Hutchinson
Tom O'Hanlon
Tom Martin
Angelo Pastore
Pat Sarube
Tony Tavella
John Vail
Tom Wodzenski Sr
John Vail
VARSITY LINE JUDGE:
SELECT ONE:
George Botsch
Peter Brown
Joe Codispoti
Blake Crespo
Larry Datz
Vic Federico
Dave Koehler
Larry Leake
Pat Mooney
Marc Negrin Jr
Cruz Pearsall
Pete Sciotto
Luis Soto
Sabina Wright
VARSITY BACK JUDGE:
SELECT ONE:
JT Andreassi
Peter Ausili
Mike Bucello
Brian Coyle
Jonathan Cruz
John Kiernan
Bob Kohn
John Krasinski
Paul Margraf
James Murnane
Bailey Negrin
John Perugini
Joe Santorrelli
Anthony Tavella
Mike Tavitian
*
Any Replacement Officials?:
Select Yes or No
No
Yes
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:
*
Briefly describe what occurred:
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.
*
DATE OF REPORT:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2023
2024
2025
2026
2027
* indicates required fields