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.

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