Form PC-2171 GHSP Application
GHSP Application
Application GHSP
GHSP Application
OMB: 0420-0561
Peace Corps Response-GHSP Application Current OMB Control Number: None
Current Expiration Date: N/A
Global
Health Service Partnership
Overview
Thank
you for your interest in applying to the Global Health Service
Partnership (GHSP). Please review the following information before
proceeding with this application.
The Peace Corps mission is to
promote world peace and friendship through the following:
•
Helping people of interested countries in meeting their need for
trained men and women
• Helping promote a better
understanding of Americans on the part of peoples served
•
Helping promote a better understanding of other peoples on the part
of Americans
Founded in
2012, GHSP is a collaboration of the Peace Corps, the U.S.
President’s Emergency Plan for AIDS Relief (PEPFAR) through the
State Department, and Seed Global Health. GHSP helps address
critical shortages of health care providers globally by placing
physicians and nurses as visiting faculty for one-year assignments in
nursing and medical schools overseas to build institutional capacity
and help strengthen the quality of medical and nursing education.
GHSP is part of the Peace Corps Response program, and GHSP Volunteers
are Peace Corps Response Volunteers.
Physician Educator
Physician Educators are needed to serve as visiting faculty in medical schools and affiliated teaching facilities/hospitals in Sub-Saharan Africa. Placements will be in medical schools and teaching hospitals where volunteers will teach students, house staff, and other learners best practice standards and enhance existing clinical training systems and structures through the development and implementation of innovative teaching tools in partnership with host country faculty. These Volunteers work under the guidance of health and education ministries, and in collaboration with host country faculty to help strengthen the quality and sustainability of physician education and clinical practice in resource-constrained countries.
Nurse Educator
Nurse Educators are needed to serve as visiting faculty in nursing schools and affiliated teaching health facilities/hospitals in Sub-Saharan Africa. In addition to teaching and mentoring students in the classroom and clinical settings, these Volunteers work closely with host country faculty and staff to enhance curricula and appropriate clinical modules and, as needed, assist in the establishment of course/clinical goals, outcomes, and program evaluation methods. Volunteers work under the guidance of health and education ministries, and in close collaboration with other institutions to increase capacity and strengthen the quality and sustainability of nursing and midwifery education and clinical practice.
Eligibility Requirements
If you are selected to serve as a Global Health Service Partnership Volunteer, you will be undertaking an exciting and life-changing experience. In addition to the skill and educational requirements listed in the Relevant Experience and Skills section, to be eligible to serve, you must
be a U.S. citizen (non-citizens may apply but must have citizenship prior to serving)
be at least 18 years of age
be a physician or nurse with an active license in the United States
meet the Peace Corps’ medical, legal and security requirements
Are you a U.S. citizen (by birth or naturalization) and at least 18 years old?
If no:
Thank you for your interest in serving with the Global Health Service Partnership. The information you entered indicates you do not meet eligibility requirements at this time. You must be a U.S. citizen and at least 18 years old to serve.
If you are under 18, please continue your spirit of service and consider the two-year Peace Corps program or Peace Corps Response again when you are older. For more information regarding eligibility requirements for Peace Corps Response service, please consult the FAQs on our website.
Are you a physician or nurse with an active license in the United States?
If no:
Thank you for your interest. The information you entered indicates you do not meet our eligibility requirements at this time.
We encourage you to consider applying to the Peace Corps Response program or consider the Global Health Service Partnership again in the future when you have an active license in the United States.
General Questions |
How did you learn about the Global Health Service Partnership?
Select One
Peace Corps Website
Peace Corps Social Media
Peace Corps Staff
Returned or Current Peace Corps Volunteer
Seed Global Health Website
Seed Global Health Social Media
Seed Global Health Staff
Internet Research
Print Media/Radio
Email Marketing/Listserv
Professional Journals
Conference/Career Event
Job Board
University Faculty/Mentor
Friends or Family
Other
If other, indicate here:
Contact Information |
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Please make sure this page contains your most up-to-date information so Peace Corps staff can contact you.
You must provide your full name as it appears on a legal document (e.g., passport, driver’s license, birth certificate, etc.).
Title (dropdown list Mr./Mrs./Miss/Ms./Dr., etc.) First name (your legal/given name) Middle name (no initials) Last name Suffix (Jr., Sr., etc.) Nickname (optional) Primary phone Secondary phone Permanent email address
The Peace Corps asks for your Social Security number because the Peace Corps Act, 22 U.S.C. 2519, requires us to do a background check on all Volunteers. The Peace Corps will also use it to ensure our records are accurate for tax and other financial accounting purposes.
Social Security number, including dashes (xxx-xx-xxxx) Please re-enter your Social Security number, including dashes (xxx-xx-xxxx)
Sex (male/female) Date of birth (day/month/year)
Current Address Please ensure that you can collect mail in a timely manner from this address, as important mail and time-sensitive forms will be sent to this address.
Address line 1 Address line 2 Country City State/Region/Province ZIP/Postal code +4 (of ZIP code)
Permanent Address For this section, please enter a permanent U.S. address where you can receive mail while overseas. If it is the same as the one above, please re-enter the address.
Address line 1 Address line 2 Country City State ZIP/Postal code +4 (of ZIP code)
Résumé/CV
Choose one of the methods below to submit your résumé /CV.
Use a résumé
/CV from my profile
By uploading your resume, you are agreeing to permit the Peace Corps to share the information in it with host country agencies and counterparts, other Volunteers, and others as the Peace Corps determines to be necessary or appropriate in connection with your application or possible future Peace Corps service.
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Education
What is the highest level of education you have achieved, or will have achieved prior to service? Please provide the information below for all academic institutions you have attended or will graduate from prior to starting your service.
School name:
If school not listed, provide name here:
Type of degree, diploma, or certificate (select one):
Date degree received or expected (mm/yyyy):
Major:
Employment History |
Please review the completed fields to ensure the information is accurate. Prior to moving on to the next page of the application, you must identify your “most recent” job.
Position or Job Title:
Organization Name:
Start year:
End year:
Most Recent:
Peace Corps Service History
Have you previously served with the Peace Corps or Peace Corps Response?
If yes:
What is your most recent Peace Corps/Peace Corps Response country of service?
When did you serve there? (MM/YYYY to MM/YYYY)
If you have additional Peace Corps/Peace Corps Response service, please list the countries and dates below.
When did you serve there? (MM/YYYY to MM/YYYY)
Relevant Experience and Skills
This section may auto-populate based upon answers that you have submitted with a previous application. Please verify that your answers address the qualifications for the position for which you are applying.
Language Skills
Please list any language experience you have beginning with the language(s) that are most relevant for the position for which you are applying. Additionally, please indicate the level of proficiency for each language selected. If you do not see the language(s) you speak in the list provided, please select the “other” option at the bottom of the list, write in the language, and indicate your level of proficiency.
Language 1
Skill Level (Novice, Intermediate, Advanced, Superior)
Language 2
Skill Level (Novice, Intermediate, Advanced, Superior)
Language 3
Skill Level (Novice, Intermediate, Advanced, Superior)
Couples
For Global Health Service Partnership applicants with a spouse or domestic partner who wishes to serve with them, Peace Corps will work to identify an appropriate Peace Corps Response assignment for the spouse or domestic partner once the GHSP applicant’s assignment location is determined. The spouse/partner of a Global Health Service Volunteer will need to apply and qualify for an assignment. If you are selected for an interview, a GHSP Peace Corps Response recruiter will contact you and provide greater detail on your request to serve as a couple. Please refer to the FAQ regarding couples in this program.
Spouses/domestic partners who do not wish to work as a Peace Corps Response Volunteer have the option to accompany the GHSP volunteer at their own expense.
Are you married or in a domestic partnership, or planning to be married or in a domestic partnership at the time you begin your service?
If yes, is your partner applying to serve with you as a Peace Corps Response Volunteer?
Please list the name of your spouse/domestic partner:
First name
Middle name
Last name
If you are unsure at this time, indicate here:
Dependents
Dependents
are not permitted to accompany Peace Corps Response Volunteers during
service. In the event that an applicant with a dependent is selected
for a Peace Corps Response position, the applicant must ensure that
adequate arrangements have been made for the care and support of the
dependent during service.
Are any persons partially or totally dependent upon you for support, whether or not they are living with you?
If yes, list all dependents and ONLY children under age 18.
Name of dependent
Relationship to dependent
Date of birth
Does the dependent live with you?
Will the dependent attend college or university during your service?
*Are
you a veteran or currently serving in the military?
Yes
No
* Do you have any military, reserve, or National Guard obligations?1
Yes
No
For more information regarding military obligations, visit peacecorps.gov/legalinfo.
The
existence of an arrest or conviction record will not automatically
exclude you from consideration for Peace Corps service. When
evaluating an arrest or conviction, the Peace Corps considers the
nature of the offense, how long ago the offense occurred, whether you
were acquitted of the offense, and other relevant facts or
indications of rehabilitation. If you are ultimately rejected for a
Peace Corps Volunteer position because of an arrest or conviction,
you can request a review of the decision and/or reapply at a later
date.
All Peace Corps invitees must undergo a
background check that will disclose all arrests and convictions,
regardless of whether the arrest or conviction has been expunged from
your record. Recent drug- or alcohol- related legal issues may be a
disqualifying factor for Peace Corps service. For more information
about the drug and alcohol policy, background check, and policies on
arrests and convictions, go to peacecorps.gov/legalinfo.
It
is your responsibility to inform the Peace Corps promptly throughout
the application process, up through the start of service, of all new
arrests, charges, citations, misdemeanors, and felonies (including
ALL drug- or alcohol-related legal incidents) and any other changes
to the information provided below, including the disposition of
existing offenses. Do not include minor traffic violations,
citations, or parking tickets.
*Are you currently involved in any court proceedings (civil or criminal) that will require your participation (as a plaintiff, defendant, or witness) during the time you would be serving as a Peace Corps Volunteer?
Yes
No
*Have you ever been cited for, arrested, charged with, or convicted of any offense? Exclude minor traffic violations, citations, and parking tickets.
Yes
No
Legal Offense2
*Type of offense (e.g., DUI, possession of marijuana, petty theft)
*Date of incident (m/d/yyyy)
*Location of incident
*Give a complete narrative explanation of the circumstances surrounding the incident. The narrative should comprehensively explain what happened leading up to the incident, what happened during the incident, and how the incident was resolved.
*Was there a final court judgment?
Yes
No
Final Court Judgment3
*List all penalties including sentence, probation, community service, fines, or other penalties imposed:
*Judgment date (m/d/yyyy)
*Current status or disposition4:
*Are you currently on probation of any kind?
Yes
No
Probation5
*What are the current requirements of your probation?
*Please state when and how your probation obligations will be met:
Additional Incidents
*Do you have any other legal incidents to report?6
Yes
No
Drug and Alcohol Policy
An
applicant with any drug-related conviction or with a conviction for
public intoxication, driving under the influence (DUI), or driving
while intoxicated (DWI), with a conviction for reckless driving after
having been initially charged with DUI or DWI, or who has a similar
alcohol-related conviction, will not have his or her application for
Peace Corps service considered until 12 months has passed from the
date of the incident. The Peace Corps may deem an applicant
unsuitable for Peace Corps service due to drug abuse, problem
drinking, and/or alcohol abuse.
An applicant who, at any time on or prior to the day of departure for Peace Corps service, is arrested for any drug offense or for public intoxication, DUI, DWI, or any similar alcohol-related offense will have any pending application or invitation for Peace Corps service withdrawn. If the charges are dismissed, an applicant whose application or invitation for Peace Corps service was terminated may immediately reapply. If the applicant is convicted of the offense, he or she may reapply after 12 months from the date of the incident.
Drug and Alcohol Use by Volunteers and Trainees Overseas
A Volunteer or trainee found to be involved with drugs in a manner not authorized for medical purposes, in any way in any country, will be administratively separated immediately. The Peace Corps enforces this strict policy not only because the cultivation, manufacturing, and trafficking, and use of drugs, including marijuana, is illegal in most countries, but also because drug involvement by Volunteers in any country could seriously jeopardize an entire Peace Corps country program, as well as the safety and health of other Volunteers and trainees.
The Peace Corps leaves decisions regarding the use of alcohol to the discretion of the individual Volunteer. The Peace Corps recognizes, however, that excessive use of alcohol may compromise Volunteer safety and security, lead to behavior that discredits the Peace Corps or the individual Volunteer, or affect the Volunteer’s performance and success in an assignment. Examples of such behavior include, but are not limited to: public intoxication, drinking while at a work site, failure to appear for work or training due to intoxication or hangovers, and verbal or physical aggressiveness while under the influence of alcohol. Such inappropriate or unsafe behavior or inability to perform adequately in the assignment may be grounds for disciplinary action, including administrative separation.
Confirmation Button
The
Peace Corps has a longstanding policy excluding individuals who have
engaged in intelligence activity or related work or who have been
employed by or connected with an intelligence agency from Peace Corps
Volunteer service, either for a specific period of time or
permanently, depending on the agency. For more information, including
definitions of “intelligence activity” and “intelligence
agency,” visit peacecorps.gov/legalinfo.
If you are a current or former employee of the Central Intelligence Agency (CIA), you are permanently ineligible for Peace Corps Volunteer service. If you are currently or were formerly employed by another intelligence agency, you are ineligible for Peace Corps Volunteer service for at least 10 years from the end date of such employment. In addition, you may be disqualified for service because your background or history discloses a substantial connection with an intelligence activity or related work other than through employment. Even family relationships to an employee of an intelligence agency may be considered a disqualifying connection. The duration of the disqualification will ordinarily not exceed 10 years and will depend on the nature of your involvement in or relationship to intelligence activities or agencies.
You should also be aware that, if you serve as a Peace Corps Volunteer, you may be ineligible for employment with U.S. government intelligence agencies for a specified period following your service as a Volunteer.
If you or a family member works for or has worked for the CIA or the National Security Agency, go to peacecorps.gov/legalinfo for further information before answering the question below.
In all other cases, if you indicate that either you or a family member has been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work, a Peace Corps representative will contact you after your application is submitted to obtain additional information and determine your eligibility for Peace Corps Volunteer service.
Based upon the preceding, please answer the following question:
*Have you or a family member ever been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work?
Yes7
No
Request for Racial and Ethnic Data (Optional)
This information is voluntary. Your response will not affect consideration of your application. By providing this information, you will assist in assuring that the Peace Corps is administered in a nondiscriminatory manner and reflects the diversity of the United States. The information requested in this section is covered by the Privacy Act Notice.
Ethnicity
Please check one of the classifications in the Ethnicity section below.
Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish" origin can be used in addition to "Hispanic" or "Latino").
Not Hispanic or Latino
Race
Please check one or more of the classifications in the Race section below.
American Indian or Alaska Native (a person having origins in any of the original peoples of North, Central, and/or South 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)
Privacy Act The Peace Corps, a U.S.
government agency , is required by the Privacy Act of 1974 (5
U.S.C. 552a) to advise you of the following information regarding
this application. The Privacy Act addresses the federal
government’s use of certain personal information in agency
files. I certify that all of the
statements made on all pages of this application, including
attachments, are true, correct, and complete to the best of my
knowledge and are made in good faith. I understand that any
misleading, inaccurate, or incomplete information may be cause for
disqualification or termination of Peace Corps service. Any
intended omission or intentionally false statement may constitute
a violation of federal and state laws and subject you to severe
civil and criminal penalties, including fines and/or imprisonment
pursuant to 18 U.S.C. 1001. *Signature *Date: MON-DD-YYYY Application Review Please verify that the
information in your application is correct by using the “Preview”
link below. To make edits to the application itself, please use
the “Previous” button at the bottom of this page (do
not press the back button). Once your application is final, click
the “Submit” button to complete the application.
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Thank you for your interest in serving as a Global Health Service Partnership Volunteer. We look forward to reviewing your application.
In addition, connect with us on Facebook and sign-up for our monthly newsletter for the most up-to-date vacancy announcements, online information sessions, and exciting stories of Volunteer service!
1 This question appears if applicant responds “Yes” to preceding question.
2 Section appears if applicant answers “Yes” to preceding question.
3 Section appears if applicant answers “Yes” to preceding question.
4 Applicant chooses from the following: guilty (including expunged/sealed), dismissed, diversion program, not guilty, deferred judgments/suspended sentence, or other.
5 Section appears if applicant answers “Yes” to preceding question.
6 Applicants can report up to five legal incidents on the Peace Corps application. After five legal incidents, the following instructions and question appear: “If there are additional legal incidents in your history, please check the box below. The Legal Eligibility Specialist may contact you for further details.”
7 If applicant selects “Yes” a Peace Corps staff member will contact the applicant for details.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Wagner, Joye |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |
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