Sexual Harassment Consent Form

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 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.