Report Bullying
Please correct the following errors.
Select School:
Bellamy
Denti
Gansevoort
John Joy
RFA
Ridge Mills
Stokes
Strough
Name
Name of Person Reporting Incident:
Where did the incident happen? (check all that apply)
School Function
Bathroom
Cafeteria
Classroom
Electronic Communications
Gym
Hallways
Locker
Off School Property
On School Property
On a School Bus
Somewhere Else
Type of Incident(s) (Check all that apply)
Physical Contact (kicking, punching, spitting, tripping, pushing, taking belongings)
Verbal Threats (gossip, name-calling, put downs, teasing, being mean, taunting, making threats)
Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation)
Abuse (actions or statements that put an individual in fear of bodily harm)
Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures, sexting)
Type of bias involved (if known): (Check all that apply)
Race
Color
Weight/Size
National Origin
Ethnic Group
Political Views
Religion
Sex
Religious Practices
Disability
Sexual Orientation
Gender
Role of person reporting incident:
Email:
Name of the target (student being bullied, harassed, or discriminated against):
Name(s) of alleged offender(s)
Date of Incident:
(MM/DD/YYYY)
Time of Incident (Include AM or PM):
What was your involvement in the incident?
Today's Date:
(MM/DD/YYYY)
Today's Current Time (Include AM or PM):
Describe the specific nature of the incident. What happened?
What happened? (Be as specific). What did the alleged offender say or do? Include any copies of text messages, emails, etc. if possible. Who was present and involved? Include names if possible.
Agreement: “I acknowledge that all of the information included in this form is accurate. This submission is a request for the Superintendent and Administration of the Rome City School District to begin an investigation."
Agree
Disagree
What would you like to submit?
Question
Comment
Suggestion
Concern
Compliment
Tell us who you are
(Select one or more)
Rome City School District Student
Rome City School District Parent/Guardian
Rome City School District Employee
Community Member
Enter the characters as shown in the image
Enter the characters as shown in the image
Required
K12
Insight
Terms of Use
and
Privacy Policy