Intermittent Roving PCMO Application Form 11_25.pdf

Updated: November 2025

INTERMITTENT ROVING PEACE CORPS MEDICAL OFFICER APPLICATION FORM

Name:

SSN: Date of birth: Place of birth:

Citizenship:

Address:

E-mail address:

Telephone (Day) : (Evening):

Available Date:

Passport Information

Passport Issuing Country:

Passport Number:

Passport Issue Date:

Passport Expiration Date:

1. 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:

• Work experience for the past ten years, including your current position

• Full description of duties and responsibilities for each position

• Start and end dates for each position held

• Salary for each position

• Number of persons supervised

• Whether full or part time

• Reason for leaving

• Names and telephone numbers of supervisors

• Volunteer positions

• Languages spoken

• Experience in:

o providing health education (including location and date) o providing emotional support and short-term counseling o training design and health-related presentation o recent experience providing gynecological care (speculum, bimanual, external exams, specimen collection), if applicable o managing/administering a health unit, if applicable o working with international organizations, if applicable

• If applicable, explanation for periods of unemployment >3 months

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

Professional Title and License number

State, Country Issue Date Expiration Date (If there is no expiration date, include an explanation).

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

Professional Title

Certifying Authority

Issue Date Expiration Date

4. 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 C.V. you are attaching, it is not necessary to repeat it here.

NAME AND ADDRESS OF

INSTITUTION

FROM-TO

DEGREE DATE

AWARDED

5. REQUIRED QUALIFICATIONS: Please answer the following questions.

Required Qualifications Please Indicate “Yes” or “No” Here

If “Yes”, describe (Organization(s) & Position Title(s), Where the Experience was Gained)

I have a minimum of five (5) years of experience working as a PCMO or in a role comparable to a PCMO in an overseas environment (i.e. not in the 50 United States or District of Columbia) within the last five years.

☐ Yes ☐ No

I have minimum of two (2) years of experience in providing health education ☐ Yes ☐ No

I have experience providing emotional support and short-term counseling

I have experience in training design and presentation of health-related material

I have experience in the management and administration of a health unit ☐ Yes ☐ No

I have knowledge of Microsoft Word, Excel, Outlook ☐ Yes ☐ No

Any unfavorable actions related to medical malpractice, clinical privileges, state license (if United States Practitioner), etc.

I have professional proficiency in English (oral, written, and comprehension)

I am able to obtain a United States of America visa

☐ Yes or N/A if US Citizen

☐ No

I am willing and able to travel to countries around the world frequently for durations ranging between 1 – 6 months

I am willing and able to maintain a flexible work schedule, which includes working a minimum of 40 hours per week, with after-hours, weekend, holiday, and on-call responsibilities.

6. QUESTIONS: Please answer the following questions.

Please use this space for explanation of any "yes" answers. Attach additional pages if necessary.

Question Please Indicate “Yes” or “No” Here

1. Has your license, certificate or registration to practice medicine or nursing ever been denied, revoked or restricted? ☐ Yes ☐ No

2. Is an action against your license, registration or certificate pending at this time? ☐ Yes ☐ No

3. Have your privileges, membership, or employment at any hospital, medical or nursing institution ever been denied or suspended? ☐ Yes ☐ No

4. Is any action pending that would deny or suspend your privileges, membership or employment at a hospital, medical or nursing institution ? ☐ Yes ☐ No

5. Do you have a substance use history that may impair your ability to serve as a medical officer? ☐ Yes ☐ No

6. Has your narcotics license ever been restricted in any manner? ☐ Yes ☐ No

7. Have you ever been convicted of a criminal offense? ☐ Yes ☐ No

8. Are any legal actions against you pending at this time? ☐ Yes ☐ No

9. Have you ever been named a defendant in a malpractice action? ☐ Yes ☐ No

10. Have you ever been denied malpractice insurance or had your malpractice insurance canceled? ☐ Yes ☐ No

11. Have you ever received other than an honorable discharge from the military? ☐ Yes ☐ No

12. In the last 5 years have you:

a. been fired from a job?

b. quit after being told you would be fired?

c. left a job by mutual agreement following allegation of misconduct?

d. left by mutual agreement following allegation of unsatisfactory performance?

e. left a job for other reasons under unfavorable circumstances?

13. If you are a Non-US Citizen: Have you ever been denied a US visa ☐ Yes

☐ No or N/A if US

Citizen

7. REFERENCES: Please submit three (3) professional references.

List names, addresses and telephone numbers of professional references or use the Reference Form provided:

o Submit one (1) reference from a supervisor and two (2) references from medical colleagues; all of whom have directly observed your work in a clinical setting, o All references must have been written within the past two (2) years (include full name and credential, current professional capacity, institution name and location, position/relation to candidate, dates working with candidate, signature of reference and stamp, if applicable), and o References should include information on both hard skills (i.e. technical experience and expertise, quality and timeliness of work product produced, etc.) and soft skills (i.e. professional judgment, professional demeanor, leadership abilities, ability to work as a member of a team, etc.).

Name Address Telephone Number

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

AUTHORIZATION FOR THE RELEASE OF INFORMATION