Hurt Feelings Report

[large][center]HURT FEELINGS REPORT[/center][/large][hr]

[center]For use of this form, see FM 22-102; the proponent agency is the NT Department of Human Resources[/center][hr]
[center]DATA REQUIRED BY THE PRIVACY ACT OF 2058[/center][hr]
[small][b]AUTHORITY:[/b] 7 NT 301, Departmental Regulations; 14 NT 20341, Minister of Information and HR.[br]
[b]PRINCIPAL PURPOSE:[/b] To assist whiners in documenting hurt feelings, and to provide leaders with a list of staff who require additional counseling, Head of Staff leadership, and extra duty....[br]
[b]ROUTINE USES:[/b] For subordinate leader development NT/SOLGOV 12-102.
Leaders and whiners should use this form as necessary.[br]
[b]DISCLOSURE:[/b] Disclosure is  voluntary, but repeated disclosure may
result in a Report of Wall to Wall Counseling.[/small][hr]
[large][center]PART I - ADMINISTRATIVE DATA[/center][/large][br][hr]
WHINER'S NAME [i]Last, First, MI[/i]: [field][br]
OCCUPATION/TITLE: [field][br]
DATE OF REPORT: [field][br]
NAME AND TITLE OF PERSON FILLING OUT THIS FORM: [field][br]
[large][center]PART II - INCIDENT REPORT[/center][/large][br][hr]
DATE FEELINGS WERE HURT: [field][br]
TIME OF HURTFULNESS: [field][br]
LOCATION OF HURTFUL INCIDENT: [field][br]
HEAD OF OFFICER SYMPATHETIC TO WHINER: [field][br]
NAME OF REAL MAN/WOMAN WHO HURT SENSITIVE FEELINGS: [field][br]
OCCUPATION/TITLE: [field][hr]
[large][center]INJURY[/center][/large][hr]
WHICH EAR WERE THE WORDS OF HURTFULNESS SPOKEN INTO?: [field][br]
IS THERE PERMANENT FEELING DAMAGE?: [field][br]
DID YOU REQUIRE A "TISSUE" FOR TEARS?: [field][br]
HAS THIS RESULTED IN TRAUMATIC BRAIN INJURY?: [field][hr]
[large][center]PART III - NARRATIVE[/center][/large][hr]
[center][i]Tell us in your own sissy words how your feelings were
hurt....[/i][/center][hr]
[field][br][hr]
[center]Authentication:[/center]
PRINTED NAME OF REAL MAN/WOMAN: [field][br]
SIGNATURE: [field][br]
PRINTED NAME OF WHINER: [field][br]
SIGNATURE: [field][hr]
[small] Please refer to Form 1703 'Hug Request Form' for supplemental support. Upon written request, we will make every reasonable effort to provide you with a "blankey", a "binky" and/or a bottle if you so desire.[/small]