Fill This Up

Name:______________________________
SOCIAL SECURITYNo:____________________
ADDRESS:___________________________
CITY:__________________________________
STAFF ELEMENT:_____________________
MALE:___________ FEMALE:___________
HOME PHONENo.:________________________
OFFICE PHONENo.:______________________
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 toperformance rating and evaluation.