Wheels in Motion
Incident / Policy Violation Report Form
Purpose
This form is used to report concerns involving participant safety or suspected violations of the Wheels in Motion Participant Safety & Sport Protection Policy. Reports may involve inappropriate conduct, abuse, harassment, bullying, grooming, discrimination, retaliation, unsafe conditions, boundary violations, sexual misconduct, or any other behavior that may place a participant or volunteer at risk.
Reports may be submitted by participants, parents or guardians, volunteers, staff, Board members, event personnel, or any other individual with a good-faith concern.
If anyone is in immediate danger, call 911 before completing this form.
Reporter Information
Name (optional if anonymous):
Phone:
Email:
Relationship to Wheels in Motion
☐ Participant
☐ Parent / Guardian
☐ Volunteer
☐ Staff
☐ Board Member
☐ Event Volunteer
☐ Witness
☐ Other: ______________________
Incident Information
Date of Incident:
Time:
Location:
Program or Event:
Person(s) Involved
Please list the names of everyone directly involved, if known.
Name(s):
Role(s) (Participant, Volunteer, Staff, Guest, etc.):
Witnesses
Please list any witnesses or individuals who may have information about the incident.
Description of the Incident
Please describe what happened in as much factual detail as possible.
Include:
- What happened
- Who was involved
- What was said or done
- When and where it occurred
- Any actions taken immediately afterward
Do not investigate the incident yourself or speculate. Simply report the facts as you know them.
Immediate Safety Concerns
Is anyone currently at risk?
☐ Yes
☐ No
☐ Unsure
If yes, please explain:
Emergency Response
Were emergency services contacted?
☐ 911
☐ Police
☐ EMS
☐ Fire Department
☐ No
Previous Reporting
Has this concern already been reported to anyone?
☐ Executive Director
☐ President
☐ Law Enforcement
☐ Move United
☐ U.S. Center for SafeSport (if applicable)
☐ Other: ______________________
Additional Information
Please provide any additional information that may assist Wheels in Motion in reviewing this concern.
Reporter Certification
I certify that the information contained in this report is true and accurate to the best of my knowledge.
Signature: ________________________________
Date: ______________________
For Wheels in Motion Use Only
Date Received: ______________________
Received By: ______________________
Case Number: ______________________
Immediate Protective Action Taken:
☐ Yes
☐ No
Investigation Initiated:
☐ Yes
☐ No
Law Enforcement Notified:
☐ Yes
☐ No
Move United Notification Required:
☐ Yes
☐ No
SafeSport Notification Required (if applicable):
☐ Yes
☐ No
Case Disposition / Notes:
Confidentiality Notice
Reports submitted to Wheels in Motion will be reviewed as confidentially as reasonably possible. Information will be shared only with individuals who have a legitimate need to know, consistent with applicable law, organizational policy, participant safety, and the requirements of Move United, the U.S. Center for SafeSport (when applicable), insurance carriers, or law enforcement.
I think this version is strong enough that it would not only satisfy Move United expectations but also stand up well if it were ever reviewed by an attorney or insurance carrier. It’s professional, neutral, and focused on documenting facts rather than asking the reporter to make conclusions. It also matches the tone and intent of your Participant Safety & Sport Protection Handbook.