Scribd
Upload
497 views

Hurt Feelings: Data Required by The Privacy Act of 1947 Authority: Principal Purpose: Routine Uses: Disclosure

This document is a hurt feelings report form used by the United States Antarctic Program. It collects information about incidents where someone's feelings were hurt, including the date and location of the incident, the names of those involved, and a narrative from the whiner describing how their feelings were hurt. The form notes that disclosure is voluntary but may lead to additional counseling. It also provides assurances that those who file reports will receive support like hugs or blankets if needed.

Uploaded by

AtaTahir
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
497 views

Hurt Feelings: Data Required by The Privacy Act of 1947 Authority: Principal Purpose: Routine Uses: Disclosure

This document is a hurt feelings report form used by the United States Antarctic Program. It collects information about incidents where someone's feelings were hurt, including the date and location of the incident, the names of those involved, and a narrative from the whiner describing how their feelings were hurt. The form notes that disclosure is voluntary but may lead to additional counseling. It also provides assurances that those who file reports will receive support like hugs or blankets if needed.

Uploaded by

AtaTahir
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

HURT FEELINGS

REPORT
For use of this form, see ASC 00-210; the proponent agency is NSB
DATA REQUIRED BY THE PRIVACY ACT OF 1947
AUTHORITY: 9 USAP 895, Departmental Regulations; 99 ASC 2211, United States Antarctic Program
PRINCIPAL PURPOSE: To assist whiners in documenting hurt feelings, and to provide leaders with a list of contractors who require additional
counseling, leadership, and extra duty.
ROUTINE USES: For subordinate leader development PAE 47-255687. Leaders & whiners should use this form as necessary.
DISCLOSURE: Disclosure is voluntary, but repeated disclosure may result in a FF Form 2908-DF, Report of Wall To Wall Counseling
PART I – ADMINISTRATIVE
A. WHINER’S NAME (Last, First, MI) B. POSITION TITLE C. SOCIAL SECURITY NUMBER
DATA D. DATE OF REPORT

E. ORGANIZATION F. NAME & TITLE OF THE PERSON FILLING OUT THIS FORM

PART II – INCIDENT
A. DATE FEELINGS WERE HURT B. TIME OF HURTFULNESS C. LOCATION OF HURTFUL INCIDENT
REPORT D. TITLE OF FOREMAN SYMPATHETIC TO WHINER

E. NAME OF REAL MAN/WOMAN WHO HURT YOUR SENSITIVE F. POSITION TITLE G. ORGANIZATION (if different from 1e above)
FEELINGS

E. INJURY (Mark all that


1. WHICH EAR WERE THE WORDS OF HURTFULNESS SPOKEN INTO? 2. IS THERE PERMANENT FEELING DAMAGE?
apply)
 LEFT  RIGHT  BOTH  YES  NO  MAYBE
3. DID YOU REQUIRE A “TISSUE” FOR TEARS? 4. HAS THIS RESULTED IN A TRAUMATIC BRAIN INJURY?
 YES  NO  MULTIPLE  YES  NO  MAYBE
F. REASON FOR FILING THIS REPORT (Mark all that apply)
I am thin skinned It hurts when I get called on my shit I got cut off at Gallagher’s
I am from Colorado or Texas I was not offered a boondoggle I got cut off at Southern
I have no sense of humor I consider myself “outdoorsy” I got cut off at the Coffee House
I am a big fucking crybaby I am a self-centered D-bag I was forced to attend an ALL HANDS
I am not all that bright The weather is too cold All of the above and more

G. NARRATIVE (Tell us in your own sissy words how your feelings were hurt.)

PART III ‐
a. PRINTED NAME OF REAL b. SIGNATURE c. PRINTED NAME OF WHINER
AUTHENTICATION d. SIGNATURE
MAN/WOMAN

We, as the USAP, take hurt feelings seriously. If you don't have someone who can give you a hug and make things all better, please let us know and
we will promptly dispatch a "hugger" to you ASAP. In the event we are unable to find a "hugger" we will notify the fire department and request
that they send fire personnel to your location. If you are in need of 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.
ASC FORM 80085-F7 PAST EDITIONS OBSELETE

You might also like