Consultation Form for Acts of Violence

　Please fill in all sections except those marked as 'Required' to the best of your knowledge.

0. I agree to the above contents. (Required)
Yes

1-1. Your Name (Required)

1-2. Your Name (Katakana)

1-3. Your Age (Required)

1-4. If under 18 years of age, have you obtained the consent of a guardian to consult using this form?　 (Required)
YesNo

1-5. Phone Number (Required)

1-6. Email Address (Required, in email format)

2-1. Name of the Person Who Suffered the Damage (Required)

2-2. Name of the Person Who Suffered the Damage (Katakana)

2-3. Age Group of the Person Who Suffered the Damage
Lower Grade Elementary School StudentUpper Grade Elementary School StudentUnspecified Elementary School AgeMiddle School StudentHigh School StudentUniversity Student20s (Excluding University Students)30s40s50s60s70s and olderOther (Including Multiple Age Groups)Unknown
2-4. Select All Applicable Types of Damage Incurred (Required)
ViolenceVerbal AbuseSexual HarassmentPower HarassmentDiscriminationOther

3-1. When (Required)

3-2. Where (Required)

3-3. By Whom (Required)
PlayerGuardianOther
3-4. Against Whom (Required)

3-5. Details of What Was Done and How It Was Done (Required)

4-1. Were There Any Witnesses to the Above Incident?
NoYes
4-2. Are There Any Other Victims? If Yes, Please Provide Their Names.

4-3. If You Have Any Supplementary Information About Evidence or Witnesses for the Above Incident, Please Provide It.

4-4. Do You Have Other Evidence to Substantiate the Incident?
YesNo

5-1. Do You Wish to Request Disciplinary Action After Agreeing to the Association's Disciplinary Policy?
YesNo
5-2. If Yes, What Kind of Action Do You Expect?

6-1. If You Are Not the Victim, Have You Obtained the Victim’s Consent to Report to the Consultation Desk?
YesNo

7-1. Name of the Perpetrator

7-2. Name of the Perpetrator (Katakana)

7-3. Age Group of the Perpetrator
Under 1020s30s40s50s60s70 and olderOtherMultiple Age Groups IncludedUnknown
7-4. Organization to Which the Perpetrator Belongs

7-5. Role/Position of the Perpetrator in the Team or Organization (Select All That Apply)
Team Manager (Head Coach)Team RepresentativeClub Activity AdvisorTeam Coach (Assistant Coach)External CoachTeammateUnknownOther

8-1. Have You Reported This Case to Any Other Organization? (Select All That Apply)
UnknownJBA CoachJBA RefereeAssociation/Federation OfficialOther

8-2. Are there any other consultation options besides this one? (Select All That Apply)
Person in charge of own team/schoolTeam/school-related persons other than the perpetratorRepresentative of team/school guardiansPolice station or police boxLegal professionals (lawyers, etc.)Consultation desk for administrative matters, etc.Association's contact pointOthers

9-1. If You Have Any Additional Information You Would Like Us to Know, Please Write It Below.

The confirmation screen will not be displayed. Are you sure you want to proceed with sending the above content? (Required)

Yes

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