PCMO Application Form 2023.docx

Revised October 2023

PEACE CORPS MEDICAL OFFICER (PCMO)

APPLICATION FORM

Solicitation #: 1145PC24R0001

PEACE CORPS MEDICAL OFFICER (PCMO)

APPLICATION FORM

Name

Name

Citizenship(s)_________________________ US Green Card Holder (Yes/No)

Address

E-mail Address

Telephone (Day) (Evening)

1. MOTIVATION: Please describe your motivation for applying for the Peace Corps Medical Officer (PCMO) personal services contract position.

2. WORK EXPERIENCE: List and attach a detailed description of all work experience over the past ten years, accounting for any periods of unemployment longer than three months. You may attach a signed resume or CV if it contains all the information requested below, including:

3. LICENSES (Include photocopies of all current, active licenses.)

Professional Title and License number

(If there is no expiration date, include an explanation).

4. CERTIFICATIONS (Include photocopies of all current certifications.)

5. EDUCATION AND TRAINING

Please list the undergraduate, graduate, nursing, or medical school you attended, dates attended, and degrees received. Include all physician internships, residencies, and fellowships. If this information is already included in the resume or CV you are attaching, it is not necessary to repeat it here.

NAME AND ADDRESS OF INSTITUTION

FROM-TO

DEGREE

DATE AWARDED

6. REQUIRED QUALIFICATIONS: Please complete the two right columns in the following chart.

A minimum of two years of relevant clinical experience in primary care after medical school in an overseas environment (i.e. not within the 50 United States or the District of Columbia) within the past five years.

Ability to communicate effectively in oral and written English.

Experience in managing mental health issues including counseling of patients.

Experience providing preventive health education and training to non-medical personnel.

Experience managing and administering health care systems, clinics, or out-patient programs.

Working knowledge of Microsoft Word, Excel, Access, Outlook.

Experience working effectively as part of an intercultural team.

Experience working with minimal supervision.

Ability to communicate effectively in oral and written Spanish (required for positions in Spanish-speaking countries only).

Ability to communicate effectively in oral and written French (required for positions in French-speaking countries only).

7. QUESTIONS: Please answer the following questions.

a. Has your license, certificate or registration to practice medicine or nursing ever been denied, revoked or restricted?

b. Is an action against your license, registration or certificate pending at this time?

c. Have your privileges, membership, or employment at any hospital, medical or nursing institution ever been denied or suspended?

d. Is any action pending that would deny or suspend your privileges, membership or employment at a hospital, medical or nursing institution ?

e. Do you have a substance use history that may impair your ability to serve as a medical officer?

f. Has your narcotics license ever been restricted in any manner?

g. Have you ever been convicted of a criminal offense?

h. Have you ever been named a defendant in a malpractice action?

i. Have you ever been denied malpractice insurance or had your malpractice insurance canceled?

j. Have you ever received other than an honorable discharge from the military?

k. In the last 5 years have you:

• been fired from a job?

• quit after being told you would be fired?

• left a job by mutual agreement following allegation of misconduct?

• left by mutual agreement following allegation of unsatisfactory performance?

• left a job for other reasons under unfavorable circumstances?

If you answered “yes” to any of the questions above (#6, a through k), please include a typewritten explanation below.

Have you ever served Peace Corps as a Trainee or Volunteer (including Response), or as a staff member (USDH, PSC, or FSN)? If yes, identify the position location, position type, title, and starting and ending dates.

8. REFERENCES

Three (3) letters of reference must be sent directly from the referring individual to the Peace Corps. At least two of the three must be from clinical colleagues. They must all be current and written within the last two years. They may be emailed to Adele Brandmark (abrandmark2@peacecorps.gov) and Elizabeth Albershardt (ealbershardt@peacecorps.gov).

9. AGREEMENT

By signing the application below and submitting it to Peace Corps in connection with this solicitation, you certify that you understand the following:

· The position is based at Peace Corps’ principal office in the country of assignment and will work under the supervision of the Country Director in the country of assignment and the Office of Medical Services at Peace Corps Headquarters in Washington, DC. This is neither a remote position nor will telework be permitted beyond that permitted by the applicable Peace Corps policies/procedures regarding personal services contractor telework in the country of assignment.

· The work schedule will be on a full-time basis (typically 260 work days authorized per contract year, with a minimum of 40 hours of work per week), with after-hours, weekend, holiday, and on-call responsibilities. The work schedule will require flexibility and frequent travel to sites within the country of assignment. The PCMO is likely not eligible for compensatory time, overtime pay, or holiday pay for hours worked beyond this minimum schedule or outside of regular working hours.

· This position requires a background investigation and certification. A security clearance may be required for US Citizens. I know of no impediments to my ability to pass a background investigation or to receive and maintain such a certification/clearance.

· This position requires a physical examination and issuance of a doctor’s medical certification. A medical clearance may be required for US Citizens. I know of no impediments to my ability to pass a physical examination or to receive and maintain such a medical certification/clearance.

· This position requires registration in the System for Awards Management (SAM) and I know of no impediments to my ability to receive and maintain such an active registration.

· This position requires the receipt and maintenance of a United States (US) visa. I have never been denied a US visa in the past and I know of no impediments to my ability to receive and maintain a US visa.

· This position requires funds to be paid electronically in US dollars. I know of no impediments to my ability to open/maintain a bank account where such payment may be deposited.

· This position requires the PCMO to follow all health and safety guidelines (including protocols such as masking, submitting to health checks/screenings and/or testing, following quarantine requirements, and following vaccination mandates, etc.) as specified for the position by the Peace Corps.

AUTHORIZATION FOR THE RELEASE OF INFORMATION

I consent to the release of information about me, and release from any liability for their statements all persons, corporations, and other entities who submit information to the Peace Corps to facilitate assessment of my qualifications. This consent includes the release of information that will help Peace Corps evaluate my professional competence, character, ethics, and other qualifications, and to resolve any doubts about my qualifications. I agree that I, as an applicant for affiliation with the Peace Corps, have the burden of producing and for resolving any doubts about such qualifications. If asked by Peace Corps, I consent to an interview to evaluate my professional and other qualifications. I understand that this information will be kept in confidence by the Peace Corps.

I certify that, to the best of my knowledge and belief, all of my statements made on this form, as well as on my resume or CV, and on all other documents submitted in connection with this application are true, correct, complete, and made in good faith.

Signature of Applicant: Date:

Name: ___________________________________________________

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