ANNUAL SAFE ENVIRONMENT VERIFICATION …

1 ANNUAL safe ENVIRONMENT VERIFICATION letter . Parish: _____. Address: _____. Audit Period (corresponds to fiscal year): _____. Dear Bishop Zubik, The above referenced parish in the Diocese, knowing the policies and practices of the Diocese related to protecting children and young people by establishing a safe ENVIRONMENT , (check one): _____ Is in full or substantial compliance with the policies and practices of the Diocese of Pittsburgh as represented in the attached checklist. _____ Is in partial compliance with the policies and practices of the Diocese of Pittsburgh as represented in the attached checklist. The plans for achieving full or substantial compliance within the next audit period include: _____. _____. _____. _____. _____. _____ Is unable to be in compliance with the policies and practices of the Diocese of Pittsburgh at this time for the following reason(s): _____.

2 _____. _____. _____. _____. Signature of Pastor/Administrator: _____. Printed Name of Pastor/Administrator: _____. Date: _____. Return signed letter and completed compliance checklist to: Most Rev. David A. Zubik, DD. c/o The Office for the Protection of Children and Young People 2900 Noblestown Road Pittsburgh, PA 15205. No later than September 30, 2016. Page 1 of 5 revised 7/2016. 2015-16 Compliance Checklist USCCB Charter for the Protection of Children and Young People Parish Name: _____. Parish Address: _____. Pastor/Admin. Initials: _____ Date: _____. Level of Compliance Part I: Parish Checklist for Compliance with the Charter as of June 30, 2016. (check ONE in each row). Area of Compliance Full Substantial Partial Non 1. Copies of the document Promise to Protect, Pledge to Heal: the Charter for the Protection of Children and Young People (revised 2011) by the United States Conference of Catholic Bishops are readily available to the faithful.

3 By being prominently placed in public areas such as the church, school, religious education, youth ministry and parish offices. 2. Copies of the diocesan safe ENVIRONMENT Policy (revised 2015) in booklet form are readily available to the faithful by being prominently placed in public areas such as the church, school, religious education, youth ministry . and parish offices. 3. Copies of the Code of Pastoral Conduct (revised June 2008) are readily available to the faithful by being prominently placed in public areas such as . the church, school, religious education, youth ministry and parish offices. 4. Copies of the Clergy Sexual Misconduct Policy (revised 2014) of the Diocese of Pittsburgh, in both English and Spanish, are readily available to the faithful by being prominently placed in public areas such as the church.

4 School, religious education, youth ministry and parish offices. 5. A copy of the 2003 diocesan policy and procedures for when an allegation of sexual misconduct is made against Church personnel other than clergy is . readily available in the parish files. 6. Parish staff is familiar with the diocesan Megan's Law Policy (Revised 7/1/2008) including the letter of Agreement (Appendix A) and a copy of . the policy is readily available in the parish files. 7. Copies of the 2015 Diocese of Pittsburgh booklet: Reporting of Child Abuse and the Child Protective Services Law of Pennsylvania are readily available to the faithful by being prominently placed in public areas such as the . church, school, religious education, youth ministry and parish offices.

5 8. The diocesan Victim Assistance Hotline telephone number (1-888-808- 1235) is published routinely in the parish bulletin (at least twice monthly) . and copies are readily available in the parish files. 9. The parish promotes and advertises education sessions for parents, and other adults on safe environments (Protecting God's Children for Adults) . and copies of the advertisements are readily available in the parish files. 10. All church personnel who have regular contact with children as defined in the diocesan safe ENVIRONMENT policy (Appendix A) have participated in the . Protecting God's Children training program. Page 2 of 5 revised 7/2016. 2015-16 Compliance Checklist USCCB Charter for the Protection of Children and Young People Parish Name: _____.

6 Parish Address: _____. Pastor/Admin. Initials: _____ Date: _____. Level of Compliance Part I: Parish Checklist for Compliance with the Charter as of June 30, 2016. (check ONE in each row). Area of Compliance Full Substantial Partial Non 11. Child Protective Services Law (CPSL) posters showing PA's ChildLine toll free number (1-800-932-0313) for reporting suspected child abuse are posted at each entrance of the church & school as . well as other appropriate places in the parish so that they are clearly visible to staff and to others who enter the premise. 12. A written parish protocol has been developed and published for reporting suspected cases of child abuse, is well known, and is . readily available in the parish files. 13. The parish/school mandated reporters (Appendix D of Policy Book).

7 Of suspected child abuse have been trained on the requirements for . reporting and the procedures in the written parish protocol. 14. The signed Acknowledgements of Receipt/Document Review for the Code of Pastoral Conduct and Child Protective Service Law are kept on file for all Church personnel (paid and volunteer) and readily . available for review. 15. Copies of the PA Criminal Record Check for all church personnel subject to the safe ENVIRONMENT Policy (Appendix A-SE Policy) are . kept on file and readily available for review. 16. Copies of the DHS Child Abuse History for all church personnel subject to the safe ENVIRONMENT Policy (Appendix A-SE Policy) are . kept on file and readily available for review. 17. Copies of the FBI Criminal Clearance or Waiver form for all church personnel subject to the safe ENVIRONMENT Policy (Appendix A-SE.)

8 Policy) are kept on file and readily available for review. 18. The following documents are kept on file in the parish office: Checklist (this form) for tracking compliance with the safe ENVIRONMENT Policy in the Diocesan-wide database. letter to applicants on the centralized database (those required to complete an application).. Instruction card to applicants on the Centralized Database . Ten Easy Steps to Create Your Electronic File. A hard copy of the Diocese of Pittsburgh Application for Employees and Volunteers. 19. ANNUAL copy of the signed & dated Pastor's VERIFICATION Form (from 2013/2104) is on file in the parish and readily available for review.. Page 3 of 5 revised 7/2016. 2015-16 Compliance Checklist USCCB Charter for the Protection of Children and Young People Parish Name: _____.

9 Parish Address: _____. Pastor/Admin. Initials: _____ Date: _____. Part II: Parish Checklist for Compliance with Record Keeping Requirements as of June 30, 2016. YES NO. 1. The parish has an active safe ENVIRONMENT coordinator (SEC) appointed by the pastor. If no, explain: _____ . _____. 2. A copy of the most recent signed and dated SEC Information Sheet has been sent to the Office for the Protection of Children and Young People and a copy is available for review at . the parish. 3. A copy of the job description for the parish safe ENVIRONMENT coordinator is on file in the parish office and available for review.. 4. A copy of Diocese of Pittsburgh safe ENVIRONMENT Policy in booklet form has been given to the staff of the parish ( , school principal, catechetical administrator, youth minister, parish.)

10 safe ENVIRONMENT coordinator), and a copy is available in the parish office for review. 5. All employees/volunteers (Appendix A) active in the parish have an application in the database and are in full compliance with safe ENVIRONMENT . If no, explain: _____ . _____. 6. The parish database is up to date with completed/submitted database applications, dates entered into workshop files for: Code of Pastoral Conduct, Child Protective Service Law, DHS Child Abuse History, State Police Criminal Record Check, FBI Clearance or Waiver . Form, Protecting God's Children training and Mandated Reporter Training, if required. 7. Originals of all compliance documents for dates entered into the database are kept in the employee/volunteer's individual SE document file.