USA ROLLER SPORTS
ROLLER DERBY GAME REPORT FORM
HOW TO USE THIS FORM
Completely fill in all applicable fields. Please submit forms to the USARS
Office within 7 days of the completion of the event.
Mail to:
For double headers or tournaments, please submit a separate form for
each game.
Fax to:
Email to:
USARS 4730 South Street
Lincoln, NE 68506
(402) 483-1465
[email protected]
Summary Sheet
Please fill out the Game Details and the Roster Information before the game. The Roster Information section allows for 20
players (15 plus up to 5 alternates) to be listed. Players not participating in the game being tracked should be crossed or
blacked out.
Make sure the Referee Information and the Support Staff/Non-Skating Official Information sections are completed before
you submit the form.
At the end of the game, please complete the score and penalty summaries, and also gather the Required Signatures from
the Captains and the Head Officials.
Lineup Sheets
Examples
Assign each player to their respective position (Blockers, Jammer and
Pivot) for the current jam by entering their number in the large
square of the appropriate column.
If a player starts a jam in the penalty box, indicate such with an 'S'
next to that player's number using the upper square under the “IN”
column for the corresponding to the jam.
If a player is sent to the penalty box during a jam, indicate such with
an 'X' next to that player's number using the “IN” column. Use the
upper square for their first trip or the lower square for their second
trip.
Once a player has been released from the penalty box during a jam,
indicate such with an 'X' next to that player's number using the
“OUT” column. Use the upper square for their first trip or the lower
square for their second trip.
Page 1
NUMBER
IN
OUT
S
X
IN
OUT
X
X
NUMBER
IN
OUT
9
X
X
X
NUMBER
IN
OUT
9
NUMBER
9
9
X
9
S
X
Player started the jam in the penalty
box and was released during the
same jam.
Player was sent to the penalty box
and was released during the same
jam.
Player was sent to the penalty box,
was released and then was sent to
the box again, all during the same
jam.
Player was sent to the penalty box
and the jam ended before their time
was served. Player then started the
next jam in the box and was later
released.
Score Sheets
Please enter your name and the name of the active scorer referee designated to the team for which you are
tracking.
JAMMER/PIVOT: Write the uniform numbers of the players who are playing the current jam for both the
Jammer and Pivot positions.
ACTIVE SCORER: During each jam, place an "X" by the number of the player who was designated as the active
scorer (“AS”), if any.
LEAD: Note if your active scorer was designated lead during the first pass by putting an “X” in the “LEAD”
column for the corresponding jam. If neither the jammer nor the pivot became active scorer, leave both boxes
blank indicating that no one completed the initial pass.
END: To be marked if your active scorer successfully called off the jam.
TOTALS: Enter the total number of points scored during the current jam under the "JAM" column. Enter the
total points for the entire game up to the current jam under the "GAME" column.
CARRY OVER: This field does not appear on the tracking sheet for Period 1. Enter the total number of points the
team you are tracking has scored in previous periods. This field will simply assist you in keeping track of the
score in order to continue adding up the jam and total game points.
Make sure you add up the Period Totals at the bottom of each page. Add the total points for each pass and
enter the total points for the period.
Penalties Sheets
Write the uniform numbers for all the players in the roster of
the team you are tracking under the “PLAYER” column.
Track each penalty committed by a player by entering the type
of penalty in the top square, the period number in the lower
left square and the jam number in the lower right square.
Examples
9
9
X
1 12
B
2
3
Player committed a "Cutting the
Track" penalty during the 12th jam
of the 1st period.
Player committed a "Back Block"
penalty during the 3rd jam of the
2nd period.
For convenience we have included a single-tracker penalty sheet (page 15), which you can use instead of the
per-team penalty sheets on pages 13 and 14 of this document.
Page 2
USA ROLLER SPORTS
ROLLER DERBY GAME REPORT FORM
GAME DETAILS
Date:
Time:
Venue:
Sanction #:
Tournament:
(leave blank for single games)
ROSTER INFORMATION
Indicate the team captain with an "X" in the C column and the alternate captain with an "X" in the A column.
HOME TEAM
VISITING TEAM
Club:
Club:
Team:
Team:
Club Id:
Uniform #
Color:
Club Id:
Player Name
C A
Uniform #
Player Name
C A
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
(ALT)
Coach
Coach
Coach
Coach
USARS Roller Derby - Summary Page
Color:
Page 3
SCORE SUMMARY
PENALTY SUMMARY
HOME
VISITING
HOME
VISITING
Points
Points
# of Penalties
# of Penalties
Period 1
Period 1
Period 2
Period 2
TOTAL
TOTAL
REFEREE INFORMATION
Legal Name
Club Affiliation
Position
SUPPORT STAFF/NON-SKATING OFFICIAL INFORMATION
Legal Name
Club Affiliation
Position
REQUIRED SIGNATURES
Legal Name
Skate Name
Signature
Head Referee
Head NSO
Home Team
Captain
Visiting Team
Captain
USARS Roller Derby - Summary Page
Page 4
Home Team:
Date:
Lineup Tracker:
Period:
JAM
PIVOT
#
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
1
JAMMER
NUMBER
BOX
IN
OUT
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
Lineup Sheet - Home Team - Period 1
Page 5
Home Team:
Date:
Lineup Tracker:
Period:
JAM
PIVOT
#
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
2
JAMMER
NUMBER
BOX
IN
OUT
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
Lineup Sheet - Home Team - Period 2
Page 6
Visiting Team:
Date:
Lineup Tracker:
Period:
JAM
PIVOT
#
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
1
JAMMER
NUMBER
BOX
IN
OUT
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
Lineup Sheet - Visiting Team - Period 1
Page 7
Visiting Team:
Date:
Lineup Tracker:
Period:
JAM
PIVOT
#
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
BLOCKER
NUMBER
BOX
IN
OUT
2
JAMMER
NUMBER
BOX
IN
OUT
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
Lineup Sheet - Visiting Team - Period 2
Page 8
Home Team:
Period:
Score Tracker:
Date:
1
JAM
JAMMER
PIVOT
P1
PASS 2
PASS 3
PASS 4
PASS 5
PASS 6
#
NUMBER AS
NUMBER AS
LEAD
POINTS
POINTS
POINTS
POINTS
POINTS
END
Active Scorer Ref:
TOTALS
JAM
GAME
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
Period 1 Totals
Score Sheet - Home Team - Period 1
Page 9
Period:
Score Tracker:
Date:
Active Scorer Ref:
Carry Over:
JAM
JAMMER
PIVOT
P1
PASS 2
PASS 3
PASS 4
PASS 5
PASS 6
#
NUMBER AS
NUMBER AS
LEAD
POINTS
POINTS
POINTS
POINTS
POINTS
END
Home Team:
2
TOTALS
JAM
GAME
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
Period 2 Totals
Score Sheet - Home Team - Period 2
Page 10
Visiting Team:
Period:
Score Tracker:
Date:
1
JAM
JAMMER
PIVOT
P1
PASS 2
PASS 3
PASS 4
PASS 5
PASS 6
#
NUMBER AS
NUMBER AS
LEAD
POINTS
POINTS
POINTS
POINTS
POINTS
END
Active Scorer Ref:
TOTALS
JAM
GAME
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
Period 1 Totals
Score Sheet - Visiting Team - Period 1
Page 11
Period:
Score Tracker:
Date:
Active Scorer Ref:
Carry Over:
JAM
JAMMER
PIVOT
P1
PASS 2
PASS 3
PASS 4
PASS 5
PASS 6
#
NUMBER AS
NUMBER AS
LEAD
POINTS
POINTS
POINTS
POINTS
POINTS
END
Visiting Team:
2
TOTALS
JAM
GAME
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
Period 2 Totals
Score Sheet - Visiting Team - Period 2
Page 12
Home Team:
Date:
Penalty Tracker:
PENALTIES
PLAYER
Number
1
2
3
4
EXP
5
6
TOTAL
7
REFERENCE
Penalty Types
B
Back Block
D
Direction of Play
E
Elbows
F
Forearms / Hands
G
Gross Misconduct
H
Blocking with the
Head
HB
High Block
I
Illegal Procedure
M
Multi-player Block
N
Insubordination
O
Out-of-Bounds
Block
P
Out of Play
S
Skating Out of
Bounds
Tripping / Low
Block
T
X
Cutting the Track
Errors tracking
period data
Jam
Period
P1 P2
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
Period 1
Period 2
Team Penalties
Penalties Sheet - Home Team
Page 13
Visiting Team:
Date:
Penalty Tracker:
PENALTIES
PLAYER
Number
1
2
3
4
EXP
5
6
TOTAL
7
REFERENCE
Penalty Types
B
Back Block
D
Direction of Play
E
Elbows
F
Forearms / Hands
G
Gross Misconduct
H
Blocking with the
Head
HB
High Block
I
Illegal Procedure
M
Multi-player Block
N
Insubordination
O
Out-of-Bounds
Block
P
Out of Play
S
Skating Out of
Bounds
Tripping / Low
Block
T
X
Cutting the Track
Errors tracking
period data
Jam
Period
P1 P2
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
Period 1
Period 2
Team Penalties
Penalties Sheet - Visiting Team
Page 14
Penalty Tracker:
Date:
Visiting Team:
Home Team:
PENALTIES
PLAYER
Number
1
2
3
4
EXP
5
6
TOTAL
PENALTIES
PLAYER
7
Number
B
D
E
F
G
H
HB
I
M
N
O
P
S
T
X
b
d
e
f
g
h
hb
i
m
n
o
p
s
t
x
1
2
3
4
EXP
5
6
TOTAL
7
REFERENCE
Penalty Types
B
Back Block
D
Direction of Play
E
Elbows
F
Forearms / Hands
G
Gross Misconduct
H
Blocking with the
Head
HB
High Block
I
Illegal Procedure
M
Multi-player Block
N
Insubordination
O
Out-of-Bounds Block
P
Out of Play
S
Skating Out of
Bounds
T
Tripping / Low Block
X
Cutting the Track
Jam
Period
P1 P2
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
Single-tracker Penalties Sheet
Use instead of the per-team penalty tracking sheets.
Page 15