Form PC-262-16 Vaccination Requirement Form

Peace Corps – Vaccination Requirements | PC-262-16 [Rev. Aug 2020]

Vaccination Requirements

The following vaccines are required for medical clearance. Other country-specific recommended vaccinations will be provided by Peace Corps after you arrive in country. Only Peace Corps Response (PCR) invitees will be instructed to receive additional vaccinations prior to departure.

Varicella (Exempt if born in U.S. before January 1, 1980)

• 2 doses in lifetime OR

• Varicella Titers showing positive varicella zoster virus (VZU) IgG antibodies OR

• 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 OR

• MMR Titers showing positive IgG antibodies to all three illnesses

Polio

• Childhood series (4 doses) AND one booster shot after age 18 OR

• 3 doses after age 18 OR

• Polio Titers showing positive neutralizing serum antibodies AND one booster shot after age 18

Tetanus diphtheria/TD and pertussis

• Booster within last 7 years AND

• Childhood series (4 doses) OR

• Adult series (3 doses) with most recent dose within last 7 years

Pneumovax (PPSV – 23)

• Required for all who are 65 or older or will turn 65 while in service

PRIVACY ACT NOTICE

Authority: This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq.

Purpose: 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.

Routine Uses: This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a(b), and the Peace Corps' Routine Uses A through N, as listed on the Peace Corps’ Privacy Program webpage, and listed in System of Records PC-17, “Volunteer Applicant and Service Records System.” 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.

Applicable SORN: System of Records PC-17, Volunteer Applicant and Service Records System.

Disclosure: 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.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average one hour per applicant and one hour per physician per response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency 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: FOIA/Privacy Officer, Peace Corps, 1275 First Street, NE, Washington, DC 20526 ATTN: PRA (0420-0550).

Peace Corps – Vaccination Requirements | PC-262-16 [Rev. Aug 2020] Page 1 of 1