Form PC-1532 Peace Corps Confidential Reference Form

OMB Control Number: 0420-0006

Expiration Date: 03/31/2018

Peace Corps Confidential Reference Form
Peace Corps Volunteers represent the United States and the American people in the countries and communities where they serve overseas. The Peace Corps expects Volunteers to conduct themselves at all times in a manner reflecting credit on the Peace Corps and the United States. Appropriate Volunteer conduct is critical because it is intimately tied not only to the reputation and effectiveness of the Peace Corps program, but even more importantly to the safety and protection of our Volunteers, and the communities and children they serve. Please consider these factors carefully when completing this recommendation. Please include any concerns that you may have about this applicant working with children while in the Peace Corps, or other information that may inform our assessment of the applicant’s suitability to serve as a Peace Corps Volunteer.
*Applicant's Name

*Your Name

Company/Organization

*Phone Number

Email Address

*I am the applicant's

 Selection details

If you selected other, please specify your relationship to the Peace Corps applicant.

*I have known the applicant since (MM/YYYY):

1.*Please check one of the following to summarize your overall recommendation of the applicant:
I recommend the applicant without reservation for Peace Corps service.
On the whole, I recommend the applicant for Peace Corps service.
I have some reservations, but I feel that he or she has a reasonable chance of success in the Peace Corps.
I have substantial doubts about the applicant's suitability for Peace Corps service. I do not know the applicant well enough to appraise his or her qualifications to serve.

In the space below, provide the rationale for the overall recommendation you selected above. Please provide as much detail as possible.

2.*Do you know of any reasons why this individual should not work with children?

Yes, I know of a reason or reasons why this individual should not work with children

No, I do not know of any reasons

CONFIDENTIALITY STATEMENT

*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 to the applicant. I realize that a summary of this reference may be released without my authority.
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. Privacy Act Statement. Section 2504 of the Title 22, United Sates Code, authorizes collection of this information. The primary use of this information, the provision of which is voluntary, is to determine whether applicants for Peace Corps Volunteer service are qualified and suitable. To extent permitted under the Privacy Act of 1974, 5 U.S. C. 552a(k) (5), this system has been exempted from the provisions of the Privacy Act of 1974, that permit access and correction. The exemption from access is limited in some instances by law to information that would reveal the identity of a confidential source. See 65 FR 53772, 53783-84 (September 5, 2000), 50 FR 1950, 1962 (January 14, 1985), and Peace Corps regulations at 22 CFR 308. 14(c). Reference Completion Time: The Peace Corps estimates that the average time to complete this form is 10 minutes, including the time to assemble the information. If you have any comments concerning the accuracy of this estimate and any suggestions for reducing it, address them to: Peace Corps, FOIA/Privacy Act Office, 1111 20th Street NW, Washington, DC 20526.
*Signature (Please type name)

*Date

 

Thank you for your assistance.

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PC-1532 (7/2014)