Report a Concern Form

If you are reporting Sexual Misconduct please click the following link to report directly to the U.S Center for SafeSport Click Here

If reporting any other form of Misconduct please complete the information below

_____________________________________________________________________________________________________________________

Report Submitted By

All reports are kept strictly confidential by SafeSport program staff. Reports may be submitted anonymously, however, providing your contact information is vastly helpful to a timely and thorough investigation. A person reporting alleged misconduct should not fear any retribution and/or consequence when filing a report he/she believes is true. Retaliation of a report made in good faith is a violation of the U.S Center for SafeSport Code of Conduct. If you are reporting Sexual Misconduct please click the following link to report directly to the U.S Center for SafeSport Click Here

First Name of Reporting Party (or Anonymous or Unknown) *

Last Name of Reporting Party (or Anonymous or Unknown) *

Phone (include area code)

Email Address * 🛈

Confirm Email * 🛈

USA Volleyball Member *

Yes

No

Region Affiliation
Click to Find Region

Club Name

Reporting Party Relationship to victim (if any) * 🛈

Self	Club Member
Parent / Guardian	Other Family Member
Coach or Volunteer	Friend or acquantance
Prefer not to say	Other Other

______________________________________________________________________________________________________________________

Person Being Reported (Respondent)

Provide as much information as possible about the person you are reporting.

Respondent First Name *

Respondent Last Name *

Approximate Age

Gender *

Male

Female

Region Affiliation
Click to Find Region *

Club Name * 🛈

Position (s) this person held or holds *

Head Coach	Assistant Coach
Club Director	Official
Athlete	Other Other

____________________________________________________________________________________________________________________________________________________

If you are reporting Sexual Misconduct please click the following link to report directly to the U.S Center for SafeSport Click Here

Alleged Offense Information

Provide as much information as you are able.

Type of Offense (select all that apply) * 🛈

Physical Misconduct

Emotional Misconduct

Bullying, Threats and Harassment

Sexual Harassment

Hazing

MAAPP Violation

Other Other

Location of incident(s) * 🛈

Date (s) of Alleged Offense * 🛈 +

Detailed Description of Incident *

Knowledge of victim (s) involved in the alleged offense *

I am not aware of any victim(s) involved in the alleged offense

I am aware of a victim(s) involved

______________________________________________________________________________________________________________________________________________________________________

Victim

All reports are kept strictly confidential by SafeSport program staff. Reports may be submitted anonymously, however, providing your contact information is vastly helpful to a timely and thorough investigation. You may also be unaware of who the victim is. In that case, please enter Unknown.

First Name of Victim (or Anonymous or Unknown) *

Last Name of Victim (or Anonymous or Unknown) *

Age or Approximate Age *

Gender *

Male

Female

Club Name (or None)

Additional Information

----------------------------------------------------------------------------------------------------------------

Additional Victim(s)

First Name of Victim

Last Name of Victim

Age or Approximate age

Club name (or none)

Gender

Male

Female

Additional Information

______________________________________________________________________________________________________________________________________________________________________

Individual(s) Who May Have Additional Information

List anyone who may be able to provide addtional information regarding the alleged offense. We will not identify you when we contact these individuals.

First Name of witness

Last Name of witness

Phone (include area code)

Email Address

Confirm Email

__________________________________________________________________________________________________________________________________________________________________________

Other Information

Enter any other information that you feel would be helpful to an investigation of the alleged offense you have reported:

Add Supporting Documents Here