Date: __________ 2008
Time of Hurtfulness: __________ am/pm
A. Which ear were words of hurtfulness spoken into? _____ left _____ right _____ both
B. Is there permanent feeling of damage? _____ yes _____ no
C. Did you need a tissue for the tears? _____ yes _____ no
Reasons for filing this report. Check which one applies:
1. ___ I am thin-skinned.
2. ___ I am a pussy.
3. ___ I have woman-like hormones.
4. ___ I am a little bitch.
5. ___ I am a queer.
6. ___ I am a cry baby.
7. ___ I want my mommy.
8. ___ All of the above.
Name of the “Real Man” who hurt your sensitive little feelings: ____________________
If you feel that you need someone to hug, go home to Mommy and let her hug you and change your diaper. If you feel as though you need to speak to someone to soothe you, please call this number: 1-800-CRY-BABY or 1-888-SIS-GIRL.
Girly Man who filed report: ____________________
Signature of Girly Man: ____________________
Real Man (person who is being brought up on charges): ____________________
Signature of Real Man: ____________________
Superintendent’s Signature: ____________________