PC-2137 Peace Corps Response Personal Reference Form

Peace Corps Response Personal Reference Form OMB Control No. 0420-0548

Expiration Date: Date

Peace Corps Confidential Reference Form

Peace Corps 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 concerns you have about this applicant working with children while in the Peace Corps; their drug or alcohol use; or other 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. Do you know of any situations or problems the applicant might be trying to avoid by going overseas as a Peace Corps Response Volunteer?

4. 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. Changes his or her behavior to accommodate others

2. Copes well with separation from family and friends

3. Flexibility in changing circumstances

4. Responds maturely to stressful working and living situations

5. Sensitivity when working with people of different backgrounds

5. 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 Peace Corps Response service.

• On the whole, I recommend the applicant for Peace Corps Response service.

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

• I have substantial doubts about the applicant's suitability for Peace Corps Response 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 Peace Corps Response Volunteer, or provide any additional information that may be helpful in our consideration of this candidate:

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: 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 request for information. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

1. This request for information is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.

2. The information you provide will be used to evaluate a Peace Corps applicant’s qualifications and suitability for Peace Corps service.

3. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records.

4. The completion of this request for information is voluntary. However, failure to complete the form may impair the ability of the Peace Corps to assess the qualifications of the applicant for consideration for Peace Corps service.

Paperwork Reduction Act Statement: Public reporting burden for this information collection is estimated to average ten minutes. This includes the time for reviewing instructions and completing the information. This is voluntary information collection. An agency may not conduct or sponsor, and persons are 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 20th Street, NW, Second Floor, Washington, DC 20526.

Signature (please type name):

Date:

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

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PC-2137