TSCA:  BULLYING, HARASSMENT, INTIMIDATION REPORTING FORM

To report a bullying situation or incidents, please complete and submit the form below.

Bullying, harassment, and intimidation are serious and will not be tolerated.  This is a form to report alleged bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and or from school, or on the Internet sent on or off school property; or that substantially disrupted the orderly operation of the school.  Bullying, harassment and intimidation mean any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities or performance, or with a student’s physical or psychological well-being.  The conduct must (1) be motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or a physical or mental ability or disability (2) be threatening or seriously intimidating.

Electronic communication means communication transmitted by means of electronic device, including a telephone, cellular phone, computer and/or pager.  Conduct that is of a sexual nature is the most commonly reported form of sexual harassment.  This term is generally thought to mean actions, language or visual materials which specifically refer to, portray or involve sexual activity or language.  Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes and inquiries about a person’s sex life.  Sexual harassment is the broader term that encompasses conduct of a sexual nature such as unwelcome sexual advances, request for sexual favors, and other verbal or physical contact of a sexual nature.  Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender specific.

If you are a student, the parents/guardian of a student, a close at all relative of a student, or a school staff member and wish to report an incident of alleged bullying harassment or intimidation, print and complete this form and return it to the principal at the students victims school.  You may contact the school for additional information or assistance at any time.  Your report will be kept confidential to protect both the victim and offender while this report is investigated.


Date of Incident: *
Date of Incident:
Name of Student/Victim: *
Name of Student/Victim:
Is alleged offender a student at TSCA: *
Name of person reporting incident: *
Name of person reporting incident:
Phone of person reporting incident:
Phone of person reporting incident: