Intermittent Roving PCMO Application Form 2024.docx

Revised March 2024

INTERMITTENT ROVING PEACE CORPS MEDICAL OFFICER (PCMO)

PERSONAL SERVICES CONTRACT

APPLICATION FORM

SOLICITATION #1145PC24R0004

INTERMITTENT ROVING PEACE CORPS MEDICAL OFFICER (PCMO)

PERSONAL SERVICES CONTRACT

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 Intermittent Roving 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:

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

Professional Title and License number

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

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

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 CV 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 complete the two right columns in the following chart.

Has a minimum of five 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.

Has a minimum of five years of clinical experience.

Has experience managing and administering health care clinics, out-patient programs, and personnel.

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

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

Has professional written and oral proficiency and comprehension in English.

6. 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.

7. REFERENCES

Three (3) letters of reference must be sent directly from the referring individual to the Peace Corps. Two of the three letters must be from clinical colleagues. They must be current and within the last two years. The letters must be e-mailed to Adele Brandmark (abrandmark2@peacecorps.gov) and Elizabeth Albershardt (ealbershardt@peacecorps.gov).

8. 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 work schedule will be full-time (averaging a minimum of 8 hours per day) on an as-needed/intermittent basis. The work schedule will require flexibility and frequent travel to Peace Corps countries worldwide. The Intermittent Roving PCMO PSC may be required to hold a duty phone and/or to respond to off-hour calls or attend off-hour meetings (i.e. nights, weekends, and holidays) related to their position. The Intermittent Roving PCMO PSC is not eligible for compensatory time, overtime pay, or holiday pay for hours worked beyond this minimum schedule.

· Up to 195 work days may be authorized per contract year (which is subject to change at Peace Corps’ discretion each year), although no minimum number of work days authorized per contract year or work days per contract year actually worked are guaranteed. Certain benefits are tied to number of work days authorized at the time the contract period (e.g. base or option period) is awarded.

· This is neither a remote position nor will telework be permitted beyond that permitted by the applicable Peace Corps policies/procedures regarding PSC telework. The Intermittent Roving PCMO PSC will be assigned to a post for all working days of their contract and will be expected to physically be present in the commuting area of that post of assignment for the length of that assignment. Individuals selected for a position under this advertisement will not be assigned to work at a Peace Corps post in their country of citizenship or permanent residence, should one exist.

· While traveling, the Intermittent Roving PCMO may be lodged at a Peace Corps residence or in another facility with a kitchen and receive a reduced daily per diem allowance during that time.

· No annual/vacation or sick leave will be included with this contract. Any days not worked during the contract period will be unpaid.

· No dependent expenses will be paid for by Peace Corps, nor assistance (e.g. securing a visa for the country of assignment) for dependents will be provided by Peace Corps.

· This position requires a background investigation and clearance and I know of no impediments to my ability to receive and maintain such a clearance (a Top Secret clearance may be required for US Citizens).

· This position requires a medical evaluation and clearance for overseas assignments worldwide and I know of no impediments to my ability to receive and maintain such medical evaluation and 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 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 Intermittent Roving PCMO to follow all health and safety guidelines (including COVID-19 protocols such as masking, social distancing, hand hygiene, submitting to temperature checks or other 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

Printed Name___________________________________________________

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