Integrity Complaint Form

NUNAWADING BASKETBALL INTEGRITY COMPLAINT FORM
Basketball should be a safe and fair place for participants. At Nunawading Basketball, we offer a safe space for people to share their experiences or to raise concerns about behaviour they’ve witnessed or experienced.

If you have information about any breaches of Nunawading Basketball's or Basketball Victoria’s Policies or By-Laws, please complete the form below.

Please provide as much detail as possible to assist with the review of your report. Please note that where information is incomplete, Nunawading Basketball may not be able to assess your report.

Your complaint may not be responded to immediately and we ask for your patience. All reported matters are important and will be treated accordingly.
REPORTING PERSON INFORMATION

If you wish to submit this form anonymously, please leave this section blank
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you identify as Aboriginal or Torres Straight Islander?*

YesNoPrefer not to say
Do you identify as a person with a disability?*

YesNoPrefer not to say
Is English your first language? If no, please fill in below*

YesNo
First language spoken blanks
Your role in Basketball*

Administrator (volunteer)Player/AthleteCoach or Team ManagerBasketball EmployeeBoard/Committee MemberParentRefereeSpectatorOther
PRIOR REPORTS OF COMPLAINTS
Have you previously reported this matter to another organisation, police or law enforcement? If yes, please provide details*

YesNo
ACTING ON BEHALF OF ANOTHER PERSON
Are you submitting this form on behalf of someone else? If yes, please provide details*

YesNo
SUBJECT OF THE COMPLAINT

Please provide details of the person or organisation allegedly involved in the prohibited conduct.
Subject 1.
Full Name of the person*

First NameLast Name
Name of Club blanks*
Please select the persons role or position*

Administrator (volunteer)Player/AthleteCoach or Team ManagerBasketball EmployeeBoard/Committee MemberParentRefereeSpectatorOther
RELATIONSHIP TO YOU
Persons relationship to youRelationship to you*
WITNESSES
Were there any witnesses to the alleged conduct? If yes, please provide details*

YesNo
ALLEGED PROHIBITED CONDUCT
Was the prohibited contact by an adult against a child (under 18)?*

YesNo
Date of Alleged Prohibited Conduct*

MonthDayYear
Date
Location of Alleged Prohibited Conduct Location*
Additional Dates of Alleged Prohibited Conduct

MonthDayYear
Date
Additional Locations of Alleged Prohibited Conduct Location
Alleged Prohibited Conduct
Select one or more*

BullyingDiscriminationMember ProtectionHarrassmentRace or ethnicity discriminationSex or gender discriminationFailing to comply with child safe practicesDisability related misconductHomophobia/Transphobia/BiphobiaMisconduct with a childOnline misconduct (eg. Social media, email)Religious belief/activity discriminationSupplying/misusing alcohol, drugs or medicinesBetting on a basketball game (Australia)Courtsiding
Description of alleged prohibited conduct (Provide as much detail as possible, including who was involved, what happened, and how you became aware of the incident. If multiple individuals were involved, clearly state their roles.) Details*
SUPPORTING DOCUMENTATION
Do you have any supporting documents or images? If yes, please attach them with this submission*

YesNo
DECLARATION

I acknowledge that:

·             This report may not be managed through Nunawading Basketball's complaint handling process and may not result in further action.

· Nunawading Basketball may liaise with, and share relevant information with Basketball Victoria, clubs and/or associations as required to manage the complaint.

·             De-identified information provided in this report may be used to identify trends and patterns of integrity issues in basketball.

· Nunawading Basketball may use this information to develop programs aimed at preventing and responding to integrity threats in the sport.

·             The information provided in this form is true and correct to the best of my knowledge.
I confirm that I have read and understood the above declaration**

Yes
Signature
Date

MonthDayYear
Date
Should be Empty:

NUNAWADING BASKETBALL INTEGRITY COMPLAINT FORM