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Home
Board of Education
Departments
Assessment
Career, Technical and Agricultural Education
District Office Personnel
Exceptional Student Services
Facilities & Maintenance
Federal Programs
Finance
Human Resources
Curriculum and Instruction
Interventions
Pre-K
Professional Learning
School Council
School Improvement
School Nutrition
School Safety
Student Services
Technology
Transportation
Schools
Cedartown High School
Rockmart High School
Polk County College and Career Academy
Cedartown Middle School
Rockmart Middle School
Cherokee Elementary School
Eastside Elementary School
Northside Elementary School
Van Wert Elementary School
Westside Elementary School
Youngs Grove Elementary School
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Home
Quick Links
Student Resources
Parent Resources
District Handbook
E-Communication
Georgia Parent Survey
Parent Tutorials
Edgenuity
Study Island
Powerschool Login
Registration Forms
2021-2022 Kindergarten Registration
Kindergarten Registration Forms - English
Kindergarten Registration Forms - Spanish
Student Registration Form
Request for Records
Registration Frequently Asked Questions
Returning to School: Roadmap Back to PSD
Staff Resources
Staff Resources
Code 5
Code 7
Employee Travel Expense Form
Field Trips
Field Trip Request
Fundraisers
Fundraiser Request & Final Report
GaDOE TLE Platform
Hotel Tax Exemption (GA)
Kelly Education
Leave Form
PowerSchool Login (Administrators)
PowerTeacher Login
PSD Webmail
Sales Tax Exemption
SherpaDesk
Video Request Form
W-9 Taxpayer ID Request
Employment
School Calendars
2020-2021 School Calender
2020-2021 School Calendar - List View
2021-2022 School Calendar
Staff Directory
2020 Teacher of the Year
MERIT Award
What is the MERIT Award?
MERIT Award Timetable
MERIT Nomination Form
2020-2021 MERIT Award Recipients
Bids and RFP's
Finance Reports
Annual Notification Statement
FY 21 BUDGET - Approved
FY 22 - Tentative BUDGET
Public Notice Tax Digest
School System Financial Information (HB139)
SPLOST schedule FY 20
Purposity
FY21 Annual Budget Calendar
FY20 Annual Budget Calendar
GOSA District Report Card
School Safety
Anonymous Tip Hotline
School Nurses & Sports Medicine
Floyd's School Nurse and Sports Medicine Homepage
Floyd Primary Care at PSD Info, FAQs, Meet the Staff
Floyd Primary Care at PSD - Patient Information Sheet
Public Service Announcements
2020 Census
Bed Bug Guidance for Parents
Coronavirus
E-Cigarettes and Vaping
Polk School District Policy JCDAA - Student Tobacco Use UPDATED
E-Cigarettes & Vaping Information from the CDC
E-Cigarettes & Vaping - Important Facts
Vaping Health Alert
DPH News Release - 2nd Vaping-Related Death
Health Advisory - Imminent Health Risks
Head Lice Guidance for Parents
Influenze Guidance for Parents
Meningitis Vaccine Information
Rabies - Georgia Department of Public Health
Rabies Information - English Version
Rabies Information - Spanish Version
Social Media Safety
Additional Forms
Athletic Pass Request
Graduation Petition--HB 91
Community Coach Packet
Alumni
Home
Harassment, Intimidation and Bullying Report
By submitting this form you acknowledge that the information entered is complete, true, and accurate.
Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
Your Information (optional)
First Name:
Last Name:
E-Mail:
Phone #:
Address:
City:
State:
Zipcode:
Incident Information
When did this incident happen?
Location of Incident:
Select a School
Please select school
Cedartown High School
Cedartown Middle School
Cherokee Elementary School
Eastside Elementary School
Northside Elementary School
Polk County College & Career Academy
Rockmart High School
Rockmart Middle School
Van Wert Elementary School
Westside Elementary School
Youngs Grove Elementary School
Precise Location
Unknown
Bus
Hallway
Classroom
Locker room
Gym
Cafeteria
Extracurricular activity
Bathroom
At lockers
Playground
Other
Your Role:
Select Your Role
Please tell us who you are
Student
Teacher
Staff Member
Administrator
Parent
Volunteer
Bystander
Other
Type of harassment, intimidation, bullying or harm:
Types of Harassment, Intimidation and Bullying
Physical involves hurting a person’s body or possessions. Physical includes:
Hitting/kicking/pinching
Spitting
Tripping/pushing
Taking or breaking someone’s things
Making mean or rude hand gestures
Verbal is saying or writing mean things. Verbal includes:
Teasing
Name-calling
Inappropriate sexual comments
Taunting
Threatening to cause harm
Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
Leaving someone out on purpose
Telling other children not to be friends with someone
Spreading rumors about someone
Embarrassing someone in public
Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
Mean text messages or emails
Rumors sent by email or posted on social networking sites
Embarrassing pictures, videos, websites, or fake profiles
More information at
stopbullying.gov
Cause of harassment, intimidation, bullying or harm:
Unknown
Age
Color
Race
Creed
National Origin
Ancestry
Marital Status
Sex
Religion
Gender Identity
Physical Attributes
Physical/Mental Abilities
Political Belief
Political Party Preference
Socioeconomic Status
Sexual Orientation
Family Status
Other
Method of harassment, intimidation, bullying or harm:
Unknown
Electronic Communication
Written Communication
Verbal
Physical
Social/Relational
Other
What is the victims age/or grade?:
Who was the person being harassed, intimidated bullied or harmed?:
What is the offenders age and/or grade?:
Who was harassing, intimidating, bullying or causing harm?:
Select Offender Type
Unknown
Student from the same district
Student from a different district
Certified staff
Volunteer
Other
Description:
By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
By checking this box you agree to the above disclaimer.