SDoL Student Services Providers & Intern Clearances Form

SDoL Student Services Providers & Intern Clearances Form

Please complete this form for any new Student Services Partner (Behavioral Health staff, School-Based Therapy, Check & Connect, Occupational Therapist, SBHC Staff, Private Duty Nurse etc.) serving students in the School District of Lancaster. The form must be completed in its entirety at least 48 hours before a new employee is to meet with a student. Once approved, the agency contact will be notified via email. *When completing the form, please have all necessary clearance documents for the partner on hand and ready to upload. As a reminder, PDE requires school districts to have the following forms for any outside staff who has contact with students: -Child Line Child Abuse Clearance -PA State Criminal History Report -FBI Clearance (must have the RAP sheet or official document. You may also send the UE ID #) -Signed Act 24 Form. We ask that you allow 48 hours for new staff to be processed. Please complete and attach the Acceptable Use Policy as well if you will be based in a school as a provider or intern. Additionally interns, please upload proof of liability insurance if required.

New Partner Employees Serving Students in the School District of Lancaster

Date of Submission*

First Name*

Preferred Name

Last Name*

Agency Name*

Agency Contact (Name)*

Please enter the name of the person responsible for the placement/oversight of staff in SDoL.

Agency Contact (Email)*

Please enter the email of the person responsible for the oversight of staff in SDoL. This person will receive automated emails when an IBHS staff's clearances are close to expiring.

Position/Program*

Select

If "Other" Please List

Building(s) (if known)*

You may choose multiple buildings.

Select

District Contact or Intern Supervisor

Clearance Attachments*

Please upload all four of the required documents: Child Line, PA State Criminal History Report, FBI Clearance, Signed Act 24 as well as Acceptable Use Policy and Confidentiality forms for those based in a school.

Drag and drop files here or

Child Line*

Effective Date (verification date)

PA State*

Effective Date ("Disseminated by" date in lower right corner)

FBI Clearance*

Effective Date

Act 24*

Date signed

District Acceptable Use Policy (if applicable)

Employee Not Approved

Send me a copy of my responses

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