Report Bullying - Bellamy - Rome City School District

Report Bullying - Bellamy

The Rome City School District and the Board of Education take bullying very seriously. We are committed to providing a positive school environment for all of our 5,500 students in Pre-K through 12th grade. By developing a bullying report through this system you are asking our School District Superintendent and Administration to begin an investigation within one full business day. You may use this online system to report bullying of any kind that may impact a student’s school day or the school environment. It is important to know that the more details you can provide in your report the more effective we can be with our investigation.

School	This is a Bellamy report - all information will be send to the Bellamy administration & Superintendent's office.
Today's Date
Name of person reporting incident
Role of person reporting incident
Phone
Email
Name of the target (student being bullied, harassed, or discriminated against):
Name(s) of alleged offender(s)
Date(s) of Incident(s)
Time(s) of Incident(s)
What was your involvement in the incident?
Where did the incident happen? (check all that apply)
	School Function
	Bathroom
	Cafeteria
	Classroom
	Electronic Communications
	Gym
	Hallway
	Locker
	Off School Property
	On a school bus
	On school property
	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, intimiation
	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)

Describe the specific nature of the incident. What happened? (Be as specific as possible). 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.
Type of bias involved (if known): (Check all that apply)
	Race
	Color
	Weight/Size
	National Origin
	Ethnic Group
	Religion
	Sex
	Religious Practices
	Disability
	Sexual orientation
	Gender

“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 of bullying, harassment and/or cyber-bullying. An investigation will begin within ONE business day.”
	I Agree

Report Bullying - Bellamy

Rome City School District

Rome

City School District

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