![]() NAME OF REAL MAN/WOMAN WHO HURT YOUR SENSITIVE F. NAME & TITLE OF THE PERSON FILLING OUT THIS FORM A. ![]() 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. 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. HURT FEELINGS REPORT DATA REQUIRED BY THE PRIVACY ACT OF 1974 DISCLOSURE: Disclosure is voluntary, but repeated disclosure may result in a DA Form 779-1A, Report of Wall To Wall Counseling PART I – ADMINISTRATIVE DATA PART II – INCIDENT REPORT FEELINGS LEFT RIGHT BOTH YES NO MAYBE YES NO MULTIPLE _ YES NO MAYBE will promptly dispatch a "hugger" to you ASAP.
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