Personal Safety Training Tally Sheet

Personal Safety Training Tally Sheet - Catholic Schools

2025-2026 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.
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?
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?
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?
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
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Personal Safety Training Tally Sheet - Catholic Schools