Form PC-2172 GHSP Professional Reference Form

Global Health Service Partnership/Peace Corps Response Professional Reference Form OMB Control No. ###

Expiration Date:

Peace Corps Confidential Reference Form

The Global Health Service Partnership (GHSP) helps address critical shortages of health care professionals globally by sending physicians and nurses to work alongside local medical and nursing faculty to build institutional capacity and help strengthen the quality of medical and nursing education. Global Health Service Partnership (GHSP) Volunteers represent the United States and the American people in the countries and communities where they serve abroad. The Peace Corps expects Volunteers to conduct themselves at all times in a manner reflecting positively on the Peace Corps and the United States. Appropriate Volunteer conduct is critical because it is intimately tied to the safety and protection of Volunteers, and that of the communities and children they serve, as well as the reputation and effectiveness of Peace Corps programs. Please consider these factors carefully when completing this recommendation. Please include any information that may inform our assessment of the applicant’s suitability to serve as a Peace Corps Volunteer.

1. How do you know the applicant?

2. How long have you known the applicant?

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

1. Ability to work under minimal supervision and with limited resources/equipment

2. Flexibility in changing circumstances

3. Interpersonal skills

4. Responds maturely to stressful working situations

5. Sensitivity when working with people of different backgrounds

4. Do you know of any reasons why this individual should not work with children? (Yes or No)

Overall Recommendation

Please select the one that best describes your overall recommendation:

• I recommend the applicant without reservation for GHSP service.

• On the whole, I recommend the applicant for GHSP service.

• I have some reservations, but I feel that he or she has a reasonable chance of success in GHSP.

• I have substantial doubts about the applicant's suitability for GHSP service.

• I do not know the applicant well enough to appraise his or her qualifications to serve.

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

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 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.

• 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.

Privacy Act Statement: Section 2504 of Title 22, United States 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. Without such information, the Peace Corps may be unable to determine the applicant’s qualifications and suitability for Peace Corps service. To the 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, pp. 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:

By clicking "Save," you will submit your response to Peace Corps Response.

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