Safe Sport Reporting Form

USA SWIMMING SAFE SPORT
REPORTING FORM

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Reporting

USA Swimming requires reporting of sexual misconduct by any member and strongly encourages reporting of any concerns relating to safe sport. USA Swimming appreciates your willingness to report inappropriate behavior. By submitting this form, you are giving permission to USA Swimming's Safe Sport Program staff to contact you.

Out of respect for the importance of this issue and to encourage honest and effective reporting, knowingly making a false or vindictive report will not be tolerated and may be a violation of USA Swimming's Code of Conduct.

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Person Being Reported

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

First name *

Last name *

Age or Approximate Age

Gender

Female

Male

Club Affiliation (or None) * 🛈

Position(s) this individual holds or held *

Head Coach	Assistant Coach
Athlete	Official
Other Other

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Alleged Offense Information

Provide as much specific information as you are able.

Type of Offense (select all that apply) *

Physical Abuse	Inappropriate Communication
Sexual Abuse	Inappropriate Touching
Travel Policy Violation	Other Other

Location that the incident(s) took place. Enter Unknown or city, state, specific location, etc *

Dates(s) of Alleged Offense 🛈

Description of Alleged Offense (include as much detail as possible) *

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

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Victim or Victims

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.

First Name (or Anonymous or Unknown) * 🛈

Last Name (or Anonymous or Unknown) * 🛈

Age or Approximate Age

Club Affiliation (or None)

Additional Information

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Fill this section out if additional victims are involved.

First Name

Last Name

Age or Approximate Age

Club Affiliation (or None)

Gender

Female

Male

Additional Information

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Individual(s) Who May Have Additional Information

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

First Name

Last Name

Phone (include area code)

E-mail Address

Club Affiliation (or None)

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First Name

Last Name

Phone (include area code)

E-mail Address

Club Affiliation (or None)

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Report Submitted By

You may remain anonymous if you wish. However, providing your information is vastly helpful to a swift and effective investigation. All reports are kept strictly confidential by Safe Sport Program staff. 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 USA Swimming Code of Conduct.

First Name (or Anonymous or Unknown) * 🛈

Last Name (or Anonymous or Unknown) * 🛈

Phone (include area code)

E-mail Address 🛈

USA Swimming Member *

Yes

No

Not Sure

LSC

Club Affiliation (or None)

Relationship to victim (if any)

Self	Parent/guardian
Other family member	Friend or Acquaintance
Club member	Coach or volunteer
Prefer not to say	Other Other

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Other Information

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

Click the SUBMIT button when you have completed the form