Documentation for Safe Environment Representing Youth
(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 	

Grade Level	Number
of Students Enrolled*	Number of
Students who completed SE Training*	Date(s)
Trained
		Number of
students whose parent(s) declined to have their child participate**	Parent
received SE training materials?
(If “no,” explain in comments section)		Number
of students absent*	Parent
received SE training materials?
(If “no,” explain in comments section)	COMMENTS	

Preschool						
Yes	No			
Yes	No		

Kindergarten						
Yes	No			
Yes	No		

1						
Yes	No			
Yes	No		

2						
Yes	No			
Yes	No		

3						
Yes	No			
Yes	No		

4						
Yes	No			
Yes	No		

5						
Yes	No			
Yes	No		

6						
Yes	No			
Yes	No		

7						
Yes	No			
Yes	No		

8						
Yes	No			
Yes	No		

9						
Yes	No			
Yes	No		

10						
Yes	No			
Yes	No		

11						
Yes	No			
Yes	No		

12						
Yes	No			
Yes	No		

* Total number of students enrolled, trained/not trained should include only those enrolled, trained/not trained during the current audit review period.
**Audit requirement: Attach copy of Parent Acknowledgement Form (Form SE-21) or official parish/school/Diocesan organization documentation indicating decline or provide written explanation

Please mark the curriculum resource used:	Grade(s) used (Preschool, Kindergarten, Grade 1, etc.)

Circles of Care		
Conversations About L.I.F.E.		
My Body is Special/My Body, My Boundaries		
VIRTUS Programs’ Healthy Relationships for Teens		

Other curriculum resources used (write in the name of the curriculum):	Grade(s) used (Preschool, Kindergarten, Grade 1, etc.)

		

		

Describe additional activities to the requirements of the Diocesan Safe Environment program to further the protection of children (e.g. Keiki I.D., participation in child abuse prevention campaign, etc.); please include dates:

Additional Comments:

TOTALS:

Total Number of
Children/Youth enrolled during the current Audit Review Period	
Total Number of Children/Youth who completed Safe Environment during the current Audit Review Period 	
Total Number of
Children/Youth whose parents declined to have their child participate during the current Audit Review Period	

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