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

Nursing License for RN's & LPN's*
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Date of RN LPN License*
Mandated Reporter Certificate *
No File Chosen
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Date of issue Mandated Reporter Certificate*
FBI Federal Background Clearance *
No File Chosen
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Date of issue FBI Federal Background Clearance*
PA State Criminal History Clearance*
No File Chosen
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Date of issue PA State Criminal History Clearance*
PA Child Abuse Clearance*
No File Chosen
File uploads may not work on some mobile devices.
Date of issue PA Child Abuse Clearance*
PDE 6004 Arrest & Conviction Form
No File Chosen
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TB Test Results*
No File Chosen
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Please upload a state issued photo id*
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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

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