Personal Safety Training Tally Sheet

							         Personal Safety Training Tally Sheet
         Religious Education Programs
         July 2009-May 2010
         Catechetical Leader _____________________________________

         Parish & Town __________________________________________


         Please complete the appropriate sections. If not applicable, mark N/A.
                                      Total # of Students      Total # of Students
                    GRADE             Enrolled in Grade      Trained (in class or at
                                                               home with a signed
                                                                 form on file)*
                        PreK-K
                           1
                           2
                           3
                           4
                           5
                           6
                           7
                           8
                           9
                          10
                          11
                          12

                      TOTALS►


Please explain any gaps between total number of students in class and total number trained:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Were materials sent home for absent students? (Do not include in total numbers trained)

   Yes      No (Circle one)

*Home-schooled students are assumed trained unless opted out by parents.
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         Personal Safety Training Tally Sheet-Religious Education Programs
         2009-2010
         Page 1 of 2
Please answer the following questions:

1. Did any parents sign Opt-Out/Acknowledgement of Training forms? Yes                No     (Circle
one)

If Yes, please attach copies of the forms and answer these questions:
       a. How many students were opted-out/declined training? _____
       b. How many students were opted out of the classroom training but received training at
       home? _____


2. Were there any parents who indicated they wished to opt out their child(ren) or train them at
home but who refused or neglected to sign an Opt-Out/Acknowledgement of Training Form?
      Yes No        (Circle one)


        If Yes, please include a record of refusal with this form. The record of refusal is an Opt-
Out/ Acknowledgement of Training form with the name(s) and grade(s) of the student(s) along
with a notation indicating that the parent did not or would not sign any forms.



The parish has received and implemented the Diocese of Manchester personal safety
training for the 2009-2010 catechetical year.


Pastor Signature ______________________________                  Date _____________



Please return this form and enclose copies of the following documents:
          1. Opt-Out/Acknowledgement of Training Forms (maintain originals at
             parish)
          2. Records of refusal (maintain original records at parish)

Send to:       Diocese of Manchester
               Attn: Mary Ellen D’Intino
               Director of Safe Environment Programs
               P.O. Box 310
               Manchester, NH 03105-0310

Deadline: May 1, 2010



       Personal Safety Training Tally Sheet-Religious Education Programs
       2009-2010
       Page 2 of 2