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 HARASSMENT:
Salutatory Greeting: ____________________
Eye-to-Eye Contact: ____________________
Eye-to-Bust Contact: ____________________
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 sustaining 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.
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