Incident and Misconduct Report Form

Full Name

Date Filed

Phone Number

Email Address

Choose One

Athlete/Participant

Coach/Adaptive Instructor/Guide

Parent/Legal Guardian

Volunteer/Staff/Spectator

Affected Athlete/Individual

Age/Category

Person(s) Accused of Misconduct

Role/Position

Witnesses (Names and Phone/Email)

Date of Incident

Approximate Time

Specific Facility/Activity Location

Nature of Alleged Violation (Check all applicable)

Breach of "Rule of Two"/Unmonitored One-On-One

Locker Room/Changing Area/Restroom Breach

Bullying, Hazing, or Harassment

Physical Misconduct or Endangerment

Adaptive Transfer/Harness Fitting Infraction

Social Media/Digital Messaging Violation

Emotional Misconduct/Public Verbal Abuse

Sexual Harassment, Misconduct, or Abuse

Detail what occurred, direct quotes, adaptive equipment involved, and any immediate actions taken:

Law Enforcement/CPS Notified?

Yes

No

Agency & Case/Ref #

U.S. SafeSport/Move United Notified?

Yes

No

Reference # (if applicable)

Signature of Submitting Party (Optional)

Date Signed