Form PC-262-16 Required Peace Corps Immunization Documentation Form

REQUIRED PEACE CORPS IMMUNIZATIONS

As part of the medical clearance requirements, the Peace Corps requires that each new Volunteer begin service with proof of immunity (vaccination or positive titers) to the following:

Required Vaccines	Ways to Provide Proof of Immunity
Varicella *Exempt if born in U.S. before January 1, 1980	2 doses in lifetime
	Titers showing positive varicella zoster virus (VZU) IgG antibodies
	Confirmed disease diagnosis of chickenpox illness (include month and year)
Measles, mumps, rubella (MMR) *Exempt if born in U.S. before January 1, 1957	2 doses in lifetime
	Titers showing positive IgG antibodies to all three illnesses
	Confirmed disease diagnosis of all three illnesses (include month and year)
Polio (childhood series and booster after age 18)	Childhood series (3 doses) AND booster after age 18
	Titers showing positive neutralizing serum antibodies
Tetanus diphtheria/TD and pertussis (childhood series and booster within the last 5 years)	Childhood series (3 doses) AND booster within last 5 years
Yellow fever (vaccination within last 7 years)	Vaccination within last 7 years Yellow fever vaccination must be documented on the World Health Organization card.

Note: Invitee cannot receive medical clearance without proof of immunity to the above noted diseases. All other CDC recommended vaccinations will be administered by Peace Corps after arrival in-country. To prevent any duplicate vaccine administration, please provide documentation for each vaccination.

PRIVACY ACT NOTICE

This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to service as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to provide this information or failure to disclose relevant information may result in the rejection of your application to become a Peace Corps Volunteer.

This information may be used for the purposes described in the Privacy Act, 5 U.S.C. 552a, including the routine uses listed in the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist, licensed clinical social worker or other medical personnel treating you or involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.