Name:______________________________
SOCIAL SECURITY No:______________
ADDRESS:__________________________
CITY:______________________________
STAFF ELEMENT:___________________
HOME PHONE No.:__________________
MALE:_____________________________
FEMALE:___________________________
OFFICE
PHONE No.:_________________
SEXUAL PREFERENCE: Male - Female Female - Female Male - Male
All of the Above
None of
the Above - Please Specify: _____________________
I CONSENT
TO THE FOLLOWING FORMS OF SEXUAL
HARRASSMENT:
Salutatory
Greeting: ___________________
Eye-to-Eye
Contact: ___________________
Eye-to-Bust
Contatct:__________________
Eye-to-Below
Waist Contact:____________
Heavy breathing
on neck: ______________
ear: _________________
other: ________________
Hands on
body: __________________
shoulder:_____________________
waist:______________________
Gluteus Maximus:_________________
other: _____________________
Feelies:
_________________________
Gropies:_________________________
Penetration
(however slight): __________________
Other:________________________
All of the Above:_____________________
MISCELLANEOUS: I WILL I WILL NOT
1. Assist
in procurement of various potions, lotions, products,
appliances,
etc. to be used during sexual harassment.
2. Assist
in procurement and maintenance of various types of substaining
apparatus.
3. Clean
up.
I CERTIFY
THAT I WILL ACCEPT SEXUAL HARASSMENT
FROM:
Anyone:
________________________________
Anyone
But: _____________________________
Only:___________________________________
SIGNATURE:
___________________________
DATE:
____________________
This form
is to be reviewed by
immediate
supervisor annually, prior to performance rating and
evaluation.