Colonial IU 20 External Agency Contractors/Interns & 

Student Teachers/Observers Credentials Form

               This form is to be completed for any individuals providing services under an agency, completing internships, student teaching                         assignments, or observing in Colonial Intermediate Unit 20 Programs.                                                                                       

                                                

Name*
Supervisor's Name*
Student's Name (if known)

Certifications and or Licenses

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Date of RN LPN License*
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Date of issue Mandated Reporter Certificate*
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Date of issue FBI Federal Background Clearance*
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Date of issue PA State Criminal History Clearance*
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Date of issue PA Child Abuse Clearance*
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Location and Program

Please choose the site location(s) you will be working/observing at.
Please choose the program associated

Nursing Verification

HR Verification