p1440 Incident Report
Please complete the form below to submit any alleged abuse, misconduct, or injury, including emotional, physical, or sexual misconduct or abuse, or any injury occurring during p1440 programming, events, or activities. Reporting is free and can be done anonymously by entering "anonymous" in the name field. By submitting this form, you are giving permission to p1440 staff to contact you regarding the alleged incident or injury, and authorizing p1440 to share all information you provide with law enforcement authorities, medical professionals, and other safety organizations at its sole discretion. p1440 encourages honest and effective reporting; knowingly making a false or vindictive report is unethical, will not be tolerated, and may be a violation of federal law. All adults working with minor athletes are mandatory reporters under federal law. If law enforcement authorities have not yet been contacted, they should be contacted immediately. If you are under the age of 13 and need to make a report to p1440 regarding an incident of abuse or injury, please contact us at athletesafety@p1440.com.
Name of person reporting incident or injury (or “Anonymous” if you wish to report anonymously)
Should p1440 need to contact you, what is your preferred method of communication?
Email
Phone
Both
Email address of person reporting incident or injury
example@example.com
Phone number of person reporting incident or injury
Please enter a valid phone number.
Type of Incident
Injury or Accident
Sexual Abuse
Physical Abuse
Emotional Abuse
Other
Name of injured or those involved, if known and if not the reporter
Date of incident or injury
-
Month
-
Day
Year
Date
Location of incident or injury (If there are multiple dates/locations, please put them in the description box below.)
Please describe the incident or injury. Provide as much specific information as you are able.
Minor Athlete's Information
If you are the victim and wish to remain anonymous, you may do so. In that case please enter your name as Anonymous. You may also be unaware of who the victim is. In that case, please enter Unknown.
Athlete's Name (First & Last, if known)
Age or Approximate Age
Gender
Female
Male
Unknown
Organization or Club Affiliation
Whereabouts of the Minor (if known)
Additional Information
Additional Information
Was the incident reported to the authorities?
Yes
No
Unknown
Further General Comments
Report Now!
Should be Empty: