USA Rugby SafeSport Reporting Form
This form is for any member or affiliated person to submit a report of Harassment, Bullying, Hazing or Abuse, allegations of physical or emotional abuse related to rugby, or any potential violations of the USAR MAAPP. *Note - if the report involved any sexual relationship, sexual abuse or sexual misconduct, the report should be submitted directly to US Center for SafeSport office at https://uscenterforsafesport.org/report-a-concern/. Any questions about the process or program can be submitted to USA Rugby SafeSport Liaison Officer, Johnathan Atkeison at jatkeison@usa.rugby.
Reporting
YOU MAY REPORT ANONYMOUSLY. If you choose to report anonymously, please write ANONYMOUS where it says "Your full name." If you would prefer to report by phone, please call 720-508-8019. Callers may remain anonymous.
Your Full Name
Your Position/Title/Affiliation
Your Phone Number
Your Email Address
Date of Complaint
-
Month
-
Day
Year
Date Picker Icon
Did this incident violate the Minor Athlete Abuse Prevention Policy?
Yes
No
Involved Parties
Please list the individuals involved, including as many of the listed fields as you can provide.The REPORTING PARTY is the person alleging a violation of the Code.The RESPONDING PARTY is the person who is alleged to have violated the Code.A THIRD PARTY REPORTER is a person who reports a possible violation of the Code, that is not the Reporting Party. A WITNESS is someone who saw or has personal knowledge of a possible violation of the Code.
Full Name
Gender
Female
Male
Non-Binary/Third Gender
Prefer to self describe
Prefer not to say
Select Role
Reporting Party
Responding Party
Third Party Reporter
Witness
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Team or Organization
Full Name
Gender
Female
Male
Non-Binary/Third Gender
Prefer to self describe
Prefer not to say
Select Role
Reporting Party
Responding Party
Third Party Reporter
Witness
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Team or Organization
Full Name
Gender
Female
Male
Non-Binary/Third Gender
Prefer to self describe
Prefer not to say
Select Role
Reporting Party
Responding Party
Third Party Reporter
Witness
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Team or Organization
Questions and Report
Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).
If you are a Covered Adult (an individual over the age of 18 who is subject to SafeSport policies), you are also required to report all instances of possible child abuse and/or neglect to appropriate law enforcement. If you are uncertain whether you are a Covered Adult, review the policies and procedures at www.safesport.org or check with your sport National Governing Body. Does this case involve possible child abuse and/or neglect?
Yes
No
Not Sure
If so, have you reported to appropriate law enforcement authorities?
Yes
No
Supporting Documentation
Photos, video, email, and other supporting documents may be attached below. 1GB maximum total size.Attachments require time to upload, so please be patient after submitting this form.
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