Diocese of Evansville Safe Environment Curriculum Verification Form
2011-2012 Academic Year

School:                                                                      City:    

Principal:                                                      Date:

This form certifies that the learning objectives outlined in the Diocese of Evansville Safe Environment Curriculum have been taught in the school named above during the course of the academic year.

The table below indicates the number of students who received safe environment instruction during the academic year and the number of students who were opted out of any portion of the material.

GRADE                                            NUMBER INSTRUCTED                        NUMBER OPTED OUT

Pre-Kindergarten:                                                            
Kindergarten:                                                                   
Grade 1:                                                                            
Grade 2:                                                                            
Grade 3:                                                                            
Grade 4:                                                                            
Grade 5:                                                                            
Grade 6:                                                                            
Grade 7:                                                                            
Grade 8:                                                                            
Grade 9:                                                                            
Grade 10:                                                                          
Grade 11:                                                                          
Grade 12:                                                                          

TOTAL:                                                                            
 

Please complete and submit this form by May 1, 2012.