Regional PCMO Mentor Application Form.doc

January 2023 January 2023 Name: ____________________________

REGIONAL PEACE CORPS MEDICAL OFFICER MENTOR

(REGIONAL PCMO MENTOR) – ASSIGNED TO PEACE CORPS/THAILAND

APPLICATION FORM

SOLICITATION #1145PC23R0013

Name

Citizenship_________________________ US Green Card Holder (Yes/No) _________________ Address

E-mail address

Telephone (Day)

(Evening)

1.MOTIVATION STATEMENT: Please describe your motivation for applying for the Regional PCMO Mentor personal services contract position.

2. WORK EXPERIRENCE: 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

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

6.

Please answer the following questions. If you answer yes to any question, please include a typewritten explanation on a separate page.

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

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

g. Are there any legal actions against you pending currently?

h. 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?

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

7.

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

A minimum of five years of experience as a Peace Corps Medical Officer (PCMO) or in a role comparable to a PCMO providing primary care in an overseas environment (i.e. not within the 50 United States or the District of Columbia).

Experience designing health education material and presenting health education and training to medical as well as non-medical personnel.

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

Willingness and ability to travel to countries within the Region or worldwide to provide mentoring and/or temporary PCMO coverage for up to 6 weeks at a time.

Willingness and ability 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.

Professional written and oral proficiency and comprehension in English.

8. REFERENCES

List names, mailing addresses, e-mail addresses, and telephone numbers of three professional references, one of whom is or was your immediate supervisor for the longest period during the past five years. Please contact them and ask them to write a letter of reference. Include the three reference letters with your application packet.

10. 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 the Peace Corps/Thailand office in Bangkok, Thailand but will report directly to the Peace Corps Headquarters in Washington, DC.

· The work schedule will be on a full-time basis (260 workdays authorized per contract year, a minimum of 40 hours of work per week). The work schedule will require flexibility and some travel to Peace Corps countries within the Region and worldwide. The Regional PCMO Mentor is not eligible for compensatory time, overtime pay, or holiday pay for hours worked beyond this minimum schedule or outside of regular working hours. This is neither a remote position nor will telework be permitted beyond that permitted by the applicable Peace Corps policies/procedures regarding PSC telework.

· While traveling, the Regional PCMO Mentor 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.

· 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 Regional PCMO Mentor 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:

Name____________________________________________________

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