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.
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