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HURT FEELINGS REPORT For use of this f orm, see FM 22-102; the proponent agency is TRADOC DATA REQUIRED BY THE PRIV AC Y AC T OF 1974 AU THORITY: PRINCIPAL PURPOSE: ROUTINE USES: DISCLOSURE:

5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Eagles E.O. 9397 (SSN) To assist whiners in documenting hurt f eelings, and to prov ide trustees with a list of members who require additional counseling, For subordinate dev elopment IAW FM 22-102. Trustees & whiners should use this f orm as necessary. Disclosure is v oluntary , but repeated disclosure may res ult in a DA Form 779-1A, Report of Wall To Wall Counseling

PART I – ADMIN ISTRATIV E DATA A. WHIN ER’S NAM E (Last, First, M I)

B. DATE OF BIR TH

E. DATE OF M EMBER SHIP

C. SOCIAL SECURITY NUMB ER

D. DATE OF R EPORT

F. NAM E & TITLE OF THE PER SON FILLING OU T THIS FORM

PART II – INCIDENT REPORT A. DATE FEELINGS WER E HURT

B. TIM E O F HURTFULN ESS

E. NAM E O F MAN /WOM AN WHO HUR T YOUR SEN SITIVE FEEL INGS

C. LOCATION O F HURTFUL INCID ENT

D. TRUSTEE SYMPATH ETIC TO WHIN ER

F. POSITIO N (if applicable)

G. ADDITIONAL COMM ENTS

E. INJURY (Ma rk all tha t apply) 1. WHICH EAR W ERE THE WORDS O F HURTFULN ESS SPOKEN INTO?

 LEFT

 RIGHT

2. IS THER E PERMAN EN T FEELING D AMAGE?

 YES

BOTH

3. DID YOU R EQUIR E A “TISSUE” FOR TEARS?

 YES

 NO

 NO

MAYBE

MAYBE

4. HAS TH IS R ESULTED IN A TR AUMATIC BR AIN INJURY?

 YES

MULTIPLE ________

 NO

F. REASON FOR FILIN G THIS REPORT (Ma rk all tha t apply) I am thin skinned

The Eagles need to fi x my problems

Two beers is not enough

I am a wimp

My feelings a re easil y hurt

My ha nds s hould be in my pockets

I ha ve woman/man‐like hormones

I didn’t sign up for this

I didn’t get my wa y

I am a crybaby

I was told tha t I a m not special

Someone made me follow the rules

I want my mommy

The wea ther is too cold

All of the above and more

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

PART III ‐ AUTHENTICATION a. PRIN TED N AME O F MAN /WOM AN

b. SIGNATUR E

c. PRINTED NAM E OF WHINER

d. SIGNATUR E

We, as the Ea gles, take hurt feelings seriousl y. If you don't ha ve someone who can gi ve you a hug and make things all better, please let us k now and we will promptl y dispatch a "hugger" to you ASAP. In the event we a re unable to find a "hugger" we will noti fy the fi re depa rtment a nd reques t tha t they send fi re personnel to your loca tion. If you a re in need of supplemental support, upon wri tten reques t, we will make every reasonable effort to provi de you wi th a "blankey", a "binky" and/or a bottle if you so desire. DA FORM IMT WF1, APRIL 2009

EDITION OF APRIL 1989 IS OBSELETE

Hurt Feelings Report (Eagles)  

form to file if feelings are hurt

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