Standard.Reference form.12-08-current.doc

Revised: 12/16/2008

Name

STANDARD REFERENCE FORM

For Peace Corps Medical Officer Applicants

To be completed by a medical colleague who has directly observed the applicant in a clinical setting.

I am applying for a contract as a Peace Corps Medical Officer (PCMO). The application process requires that I obtain professional references using this form, and that the individuals supplying references return the completed form directly to:

The local Peace Corps office if applying from overseas;

Or if applying within the United States to:

Paul D. Coverdell Peace Corps Headquarters

Office of Medical Services

1111 20th St. NW

Washington, DC 20526

Attention: PCMO Program Coordinator, Fax: 202.692.1596

I consent to the release of information about me to the Peace Corps and have signed below. I release from any liability for their statements, all persons, corporations, and other entities who submit information at the request of the Peace Corps to facilitate assessment of my qualifications. This consent includes the release of information for the purpose of accurate evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.

Signature of applicant

Date:

Print Name

Address

Telephone

Please complete all parts of this form and return it at your earliest convenience. If you need more space, please use a separate sheet of paper. Information you provide will be reviewed by selection panels, including Peace Corps Country Directors who are considering the applicant.

VERIFICATION

In what capacity do you know the applicant?

The applicant was/is affiliated with __________________________________________________________

(institution) in the capacity of _______________________________ from ________ to _____________________

How long have you known the applicant? ______________________________________________

Actions taken: If you answer "yes" to any of the questions, please provide a typewritten explanation on a separate page.

1.

During the time noted above, has this provider ever been subject to any disciplinary action, e.g. monitoring, changes in clinical privileges?

2.

To the best of your knowledge, has the applicant ever been under investigation by any legal or professional entities?

3.

To the best of your knowledge, have there been, or are there now, any malpractice actions against this provider?

4.

If this provider left your organization, were any actions taken against him/her?

EVALUATION

Please rank the applicant’s skills and abilities using the following formula:

Superior

Good

Needs improvement

Poor

NI

No information or insufficient information to make a judgment

I.

Prevention/Health Education. The Applicant:

Designs and conducts substantial prevention and health education programs.

II.

Clinical Care. The Applicant:

Provides primary care for common illnesses and injuries.

Demonstrates clinical competence

Demonstrates technical skill

Uses professional judgment

Provides appropriate case management

Maintains good patient relationships

Arranges prompt referrals as indicated (and where possible)

Makes appropriate decisions with respect to medical evacuations.

Arranges and accompanies clients on medical evacuations as required.

Provides 24-hour on-call support.

III.

Mental Health Support. The Applicant:

Provides a significant amount of effective mental health and emotional support to clients, following established guidelines.

Evaluates and manages clients with real or suspected alcohol/substance abuse problems, following established guidelines.

IV.

Program Management. The Applicant:

Maintains current, complete and accurate documentation in medical records.

Understands and follows rules of medical confidentiality.

Is capable of projecting and planning for Volunteer health system needs annually, managing and accounting for a budget, and maintaining pharmaceutical, medical supply, and equipment inventories.

Participates fully as a member of the staff.

Works and communicate well with others.

If this provider left your organization, did s/he do so voluntarily?

ADDITIONAL INFORMATION

To the best of your knowledge, is there anything that may adversely affect the applicant's ability to fulfill the roles and responsibilities of the PCMO? It is likely that these responsibilities will include traveling, working, and living in remote, isolated areas of the developing world. It is possible that the PCMO may be the only western-trained health care provider in the area.

RECOMMENDATION

I recommend this individual without reservation.

I recommend this individual with the following reservation(s):

I do not recommend this individual for the following reason(s):

My general opinion of the applicant is:

Signature:

Print:

Title:

Date:

I can be contacted by telephone at: