PC 2105-B PCR Personal Reference Form

OMB Control No. 0420-xxxx

Expiration Date: xx/xx/20xx

Reference Form for Peace Corps Response Candidates

(Personal)

Response Applicant

Name:

Peace Corps Country Served & Assignment Area:

Peace Corps Response Country:

Project Description

Reference

Your Name:

Phone Number:

Relationship to Applicant:

1. How long have you known the applicant? Do you feel you know the applicant well enough to make a recommendation?

2. Do you know of any situations or problems that the applicant may be trying to avoid by going overseas as a Peace Corps Response Volunteer?

3. Please describe how this volunteer experience with Response would fit into the applicant’s previous experiences or future plans.

4. Please give a rating on a scale of 1 - 5 (with 1 being the lowest and 5 the highest) of the applicant’s abilities in the following areas:

a. Provided leadership/supervision __

b. Been a self-starter __

c. Worked with limited resources and equipment __

d. Changed his or her behavior to accommodate others __

e. Flexibility in changing circumstances __

f. Patience in working with individuals whose work style i.e. adherence to time,

differs from one’s own ­­__

g. Sensitivity when working with people of different backgrounds __

h. Responds maturely to stressful working and living situations __

i. Copes well with separation from family and friends __

5. Please explain any low (1-3) ratings given in 4 a-i:

Final recommendation

Please check one of the following that best describes your final recommendation:

a. Recommend without reservation as an excellent applicant. _______

b. Recommend as a good applicant. _______

c. Recommend as a fair applicant (some reservations). _______

d. Not recommended. _______

Please describe any reservations you have about the applicant's ability to serve as a Peace Corps Response Volunteer:

The Privacy Act is a federal law that states that everyone has the right to know about and receive information about, or copies of, documents about them that are maintained by the federal government. This law provides that the Peace Corps may keep the identity of the source of this reference confidential only if you request that it be kept confidential. Please indicate below whether you do or do not wish your identity revealed to the applicant.

□ I DO NOT authorize the Peace Corps to identify me as the source of this reference, nor do I authorize the Peace Corps to release a copy of this reference in its entirety to the applicant, I realize that a summary of this reference may be released without my approval.

□ I AUTHORIZE the Peace Corps to identify me as the source of this reference and to release a copy of this reference, upon request, to the applicant.