Documentation for Safe Environment Representing Adults
(Articles 12 and 13 of the Charter for the Protection of Children and Young People)
Name of Parish/School/Diocesan Affiliated Organization:  	 Address/City/Zip Code:  	

For the Fiscal Year Ended June 30, 20 	

Provide the number of persons in each category:

à To the extent possible, if persons belong in more than one category, count them in their primary category (e.g. educators who are also parents should be counted as educators; catechists who are also employees should be counted as employees).
à NOTE: Do NOT include priests and deacons in your count; these numbers will be obtained directly from the Diocese of Honolulu's Office of Clergy.

Definitions:

Educators – salaried teachers in diocesan and parish schools (include principals and administrators).

Parish Employees – paid persons (other than priests/deacons) who are employed by and work directly for parishes, including but not limited to parish ministers, rectory personnel, bookkeeper, etc.

School Employees – paid persons (other than teachers/principals and administrators) who are employed by and work directly for schools, including but not limited to school support staff, cafeteria staff, etc.

Diocesan Affiliated Employees – paid persons who are employed by and work directly for the diocesan affiliated organization such as Directors, Chairpersons, President, etc.

Volunteers/Others – non-paid persons whose duties include contact with minors, who assist the parish/school/diocesan affiliated organization, including but not limited to catechists, youth ministers, coaches, etc.

PARISHES

Total Number	
Of Total Number, How Many Have Completed Background
Screening?	
Completion Date for Those not Background Screened	
Of Total Number, How Many have completed Safe Environment Training?	
Completion Date for those not Safe Environment Trained	
PARISH	

Parish Employees
(part & full-time)

						

Volunteers/Others (whose duties include contact with minors)						
PARISH	Use the space below to explain any gaps between the total numbers and the numbers remaining to be trained
and/or complete background screening.	

Parish Employees
(part & full-time)		

Volunteers/Others (whose duties include contact with minors)		

SCHOOLS

Total Number	
Of Total Number, How Many Have Completed Background
Screening?	
Completion Date for Those not Background Screened	
Of Total Number, How Many have completed Safe Environment Training?	
Completion Date for those not Safe Environment Trained	
SCHOOL	

Educators
(part & full-time)						

School Employees
(part & full-time)						

Volunteers/Others (whose duties include contact with minors)						
SCHOOL	Use the space below to explain any gaps between the total numbers and the numbers remaining to be trained
and/or complete background screening.	

Educators
(part & full-time)		

School Employees
(part & full-time)		

Volunteers/Others (whose duties include contact with minors)		

DIOCESAN AFFILIATES

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Total Number	
Of Total Number, How Many Have Completed Background
Screening?	
Completion Date for Those not Background Screened	
Of Total Number, How Many have completed Safe Environment Training?	
Completion Date for those not Safe Environment Trained and/or Background Screened	
DIOCESAN AFFILIATE	

Diocesan Affiliate
Employees
(part & full-time)						

Volunteers/Others (whose duties include contact with minors)						
DIOCESAN AFFILIATE	Use the space below to explain any gaps between the total numbers and the numbers remaining to be trained and/or complete background screening.	

Diocesan Affiliate
Employees
(part & full-time)		

Volunteers/Others (whose duties include contact with minors)		

Page 5 of 5

I certify that the parish/school/diocesan affiliated organization has implemented the diocesan safe environment program and that the information reported here is accurate.

Name of person completing this form (please print clearly): 	Title:  	

Signature: 	Date:  	

Phone Number: 	Email:  	

Name of Pastor or Principal (please print clearly): 	Title:  	

Signature: 	Date:  	
Required for Parishes and Schools