Personal Safety Training Tally Sheet

Personal Safety Training Tally Sheet - Catholic Schools

2024-2025 School Year
You may submit this form electronically or print and mail it, along with copies of any declination forms to:

Diocese of Manchester
Attn: Cinzia Broketa
153 Ash Street
Manchester, NH 03104
cbroketa@rcbm.org

DUE DATE: MAY 1st
Principal*

First NameLast Name
School*
Town*
Which lesson(s) did you use? Select all that apply.

Circles of CareNetSmartzFamily LessonCMG That's Not OK!
Please complete the applicable sections. If not applicable, mark as "0".*
Please explain any gaps between total number of students enrolled and total number trained:
Did any parents sign Declination Forms?*

YesNo
If yes, please indicate the number of students whose parents signed Declination Forms and send copies of the forms to the address noted above.*
# of students whose parents signed Declination Forms
Were there any parents who indicated they did not want their child(ren) to participate but who refused or neglected to sign a Declination Form?*

YesNo
If yes, please indicate the number of students whose parents did not sign Declination Forms and send a record of refusal to the address noted above. The record of refusal is a Declination Form with the name(s) and grade(s) of the student(s) along with a notation indicating that the parent declined training, but did not or would not sign any forms.*
# of students whose parents did not or would not sign Declination Forms
To the best of your knowledge, were absent students trained in a previous year?*

YesNoN/ANot Known
By submitting this form, I agree that the information contained herein is true to the best of my knowledge:
Name of person completing this form*

First NameLast Name
Date*

MonthDayYear
Date
Email of person completing this form*
example@example.com
Please verify that you are human*
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Personal Safety Training Tally Sheet - Catholic Schools