Form PC-2147 Applicant Withdraw Survey

OMB Control Number: 0420-0545

Expiration Date: 9/30/2017

VRS Survey 3: Applicant Withdraw

The purpose of this survey is to gather information related to your experience with the Peace Corps as well as your primary reason for withdrawing your application to the Peace Corps. The information you provide is voluntary and you are free to not answer any of the following questions. In addition, your responses are anonymous and will be reported in a way that ensures that you will not be personally identifiable by the answers that you provide.

Public reporting burden for this information collection is estimated to average 5 minutes.  The Peace Corps may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: the FOIA Officer, Peace Corps, 1111 20^th Street NW, 2^nd Floor, Washington, D.C. 20526 or [email protected].

Please indicate your primary reason for withdrawing your application to the Peace Corps.
	Career Alternatives
	No Longer Interested In Peace Corps
	Personal reasons – Health, Family, Romantic involvement
	Returning To School
	Financial Burden of Service
	Health/Safety Concerns while serving
	Applied Too Early
	Did Not Like Country/Region of Assignment
	Length Of Processing Time
	Did Not Like Job Assignment/Work Sector of Assignment
	Family/Friends did not support decision to serve in Peace Corps
	Medical process and cost
	Offered Waitlist and Declined
	Other

Did you participate in an interview with a Placements and Assessment Specialist after you submitted your application?
	Yes
	No

If interviewed, did you receive an invitation to serve in a specific Peace Corps assignment?
	Yes
	No

Would you consider applying for Peace Corps service in the future?
	Yes
	No
	Not Sure

To conclude this survey, we would like to ask you a few demographic questions. As with all questions on this survey, your responses are anonymous and will be reported in a way that ensures that you will not be personally identifiable by the answers that you provide. If you do not feel comfortable sharing your demographic information, however, you are always free to skip or select "Prefer not to answer" for any of the following questions.

GENDER

What is your gender?
	Male
	Female
	Prefer not to answer

ETHNICITY

Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
	Yes
	No
	Prefer not to answer

RACE

Please select the racial category or categories with which you most closely identify by placing an “X” in the appropriate box. Check as many as apply.
	American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
	Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	Black or African American. A person having origins in any of the black racial groups of Africa.
	Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	White.  A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
	Prefer not to answer

AGE

What is your age?
	18 to 25
	26 to 30
	31 to 35
	36 to 45
	46 to 55
	56 to 65
	65+
	Prefer not to answer

REGION

In which state do you live? [DROPDOWN LIST OF STATES, RECODE INTO REGION, INCLUDE PREFER NOT TO ANSWER]
	Dropdown list of States including territories
	I live outside of the United States
	Prefer to not to answer