This form is provided for the reporting of disciplinary incidents related to members of Rugby Virginia State-Based Rugby Organization.

In addition to completion of this report, please provide notice of this submission to the Managing Director of Rugby Virginia (, in order to ensure appropriate processing of this submission.

Date of Incident:

Question Title

* Date of Incident:

Location of match:

Question Title

* Location of match:

Offender's Name (required):

Question Title

* Offender's Name (required):

CIPP Number (required):

Question Title

* CIPP Number (required):

[If you do not have the player's USA CIPP number, go to the USA Rugby Club Roster site (click here to access) and look for the player's number under his/her club. If the player is not listed under the club, please note this in the comments and enter "9999999" for the number.]
Position of Player/Offender's Role:

Question Title

* Position of Player/Offender's Role:

Match Level of Play/Gender:

Question Title

* Match Level of Play/Gender: