At the bottom of this page is an image of a form for plea colloquies used in Adams County, PA.
Use
The form is used by defendants, defense attorneys, prosecuting attorneys, and the court when a case is resolved through a plea. The defense attorney is required to go over the form with the defendant. Both are required to sign it. So is the prosecutor if there is a plea agreement. The completed form is provided to the court.
Reference
Local Rules 590.1 and 590.2