USA Swimming Violation Reporting Form

Report Submitted By:

You may remain anonymous; however, providing your information contributes to a swift and effective investigation. All reports are kept confidential pursuant to USA Swimming’s National Board of Review Procedures. Retaliation of a report made in good faith is prohibited under the USA Swimming’s Rulebook, the USA Swimming Whistleblower and Anti-Retaliation Policy and/or the SafeSport Code for the Olympic and Paralympic Movement.

First Name (or Anonymous or Unknown): *

Last Name (or Anonymous or Unknown): *

Phone (Include Area Code): *

Email Address:

USA Swimming Member? *

Yes

No

Not Sure

LSC:

Club Affiliation (If Applicable):

Relationship to harmed/aggrieved party (if any):

Self

Other family member

Club member

Parent/guardian

Friend or acquaintance

Coach or volunteer

Prefer not to say

Other, please specify Other, please specify

Person Being Reported:

First Name: *

Last Name: *

Age or approximate age: *

Gender: *

Male

Female

Club Affiliation (or none): *

Position this person holds: *

Location of Incident:

Location name: *

Street Address *

City: *

State: *

Zip: *

Alleged Offense

(USA Swimming Rulebook can be found here: www.usaswimming.org/rulebook )

Type of Offense, select all that apply. Articles: *

303.5
304.3.1
304.3.2
304.3.3
304.3.4
304.3.5
304.3.6
304.3.7
304.3.8
304.3.9
304.3.10
304.3.11
304.3.12
306.1
306.2
307.1
Other: Other:

USOPC Bylaws: please specify USOPC Bylaws: please specify

Ted Stevens Olympic and Amateur Sports Act: please specify Ted Stevens Olympic and Amateur Sports Act: please specify

A Conviction under State or Federal Law : please specify A Conviction under State or Federal Law : please specify

Location that the incident took place:

Date(s) of alleged incident:

Description of alleged offense: *

Individual(s) Who May Have Additional Information

Person 1:

First Name:

Last Name:

Phone (Include Area Code):

Email Address:

LSC:

Club Affiliation (If Applicable):

Person 2:

First Name:

Last Name:

Phone (Include Area Code):

Email Address:

LSC:

Club Affiliation (If Applicable):

Person 3:

First Name:

Last Name:

Phone (Include Area Code):

Email Address:

LSC:

Club Affiliation (If Applicable):

Relief Sought:

Other Information:

Please upload any relevant documents here:

Anti-Retaliation Statement:

No USA Swimming Board members, officers, employees, members, athletes, committee members, task force members, hearing panel members, volunteers, good faith reporter or other reasonable party (e.g., witnesses, victims, etc.) shall suffer harassment, intimidation, adverse employment or livelihood consequences, or any other form of retaliation (“Retaliation”) for (i) making a good faith report of a violation to USA Swimming, the USOPC, or the U.S. Center for SafeSport (the ”Center”), or (ii) participating in an investigation by USA Swimming, the USOPC, or the Center, or an inquiry or investigation by any court, law enforcement, or other governmental or administrative body. “Retaliation” also includes retaliation as described in Article 307 of the USA Swimming Rulebook and the definition of retaliation included in Section 220501(b)(11) of the Ted Stevens Olympic and Amateur Sports Act (the “Act”).

Additionally, no employee, contractor, agent, volunteer, or USA Swimming itself shall take or threaten to take any action against an athlete as a reprisal for disclosing information to or seeking assistance from the Office of the Athlete Ombuds as outlined in Section 220509(b)(5) of the Act.