Form PC-2134 Rating Tool Interview Form

OMB Control Number: 0420-0555

Expiration Date: 01/31/2018

Rating Tool Interview Form

Interview

Introduction

1. Why do you want to be a Peace Corps Volunteer?

2. What resources have you been using to learn about and best prepare yourself for Peace Corps service?

3. Why are you interested in serving in this country?

4. What languages have you studied and for how long?

Cultural Agility

5. Please tell me about a meaningful experience you have had living or working with people from another culture.

6. Please describe a time when you worked in an unstructured environment.

Motivation and Commitment

7. Please tell me about a time when you were successful at fulfilling an important commitment that turned out to be more difficult than you thought it would be.

Productive Competence

8. Please tell me about the most challenging experience that you have had working on a team of three or more people.

9. Please tell me about an experience when you were able to transfer knowledge or a skill to others.

Emotional Maturity

10. Please tell me about a time when you failed to accomplish a desired goal. This may be a professional, volunteer or academic experience.

Expectations for Service

Please tell me about any concerns you have related to the challenge and if not, why not.

11. Different and/or lack of familiar foods; lack of variety in diet. Are you a vegetarian?

12. Different living conditions or lack of modern conveniences.

13. Separation from family/friends/significant other.

14. Modifying appearance: A Volunteer’s appearance has an effect on the relationship with the community, and the Peace Corps expects Volunteers to dress in a manner similar to their host community/country.

15. Lack of privacy with host family or lack of privacy in the community.

16. Geographic isolation or isolation from other Volunteers.

17. Prescribed gender roles, including roles that may be considered “traditional” or “conservative.”

18. Volunteers are going to be in the minority. This could be due to ethnicity, race, physical attributes, sexual orientation, gender identity, religion, or other traits.

19. Personal religious requirements or possible lack of access to your own religious services. Serving in a region where there is a predominant religion.

20. Are you comfortable living in a culture that prohibits the use of alcohol altogether or living in a culture where alcohol may be widely consumed and consumption is expected?

21. Do you have concerns about there being restrictions on your personal use of drugs and alcohol during service, as outlined in the Peace Corps Drug and Alcohol Policy?

Legal

22. Do you understand the Peace Corps’ Drug and Alcohol Policy?

23. Do you acknowledge and understand that it is your legal obligation to inform Peace Corps within five days of any legal incidents that occur up to your day of departure (excluding traffic violations less than $300 that are not alcohol or drug related)?

24. Do you acknowledge and understand that the Federal Background Investigation will reveal all previous legal incidents, regardless of the outcome of the incident?

25. Do you acknowledge and understand that if you fail to disclose any required information about your legal history – including expunged or sealed cases – or drug/alcohol behavior, the Peace Corps may revoke your invitation to serve, or disqualify you from Peace Corps service?

26. The interview is your final opportunity to disclose information regarding your prior legal history. Is there any new information regarding your legal history that you would like to reveal at this time?

Privacy Act Statement¹

The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this interview. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

A. This interview is part of the application process for Peace Corps service, which is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.

B. The information you provide will be used is to evaluate whether you meet the eligibility and selection standards for service as a Peace Corps Volunteer.

C. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records.

D. Provision of the information requested in this interview is voluntary. However, failure to provide the requested information will result in the Peace Corps being unable to assess your qualifications and may preclude your consideration for the Peace Corps.

Paperwork Reduction Act Statement²

This is a voluntary information collection. You are not required to respond unless we display a currently valid OMB control number. The control number for this collection is 0420-0555 and expires XX/XX/XXXX. The public reporting burden for this information collection is estimated to average 90 minutes. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: the FOIA Officer, Peace Corps, 1111 20th Street NW, 2nd Floor, Washington, D.C. 20526.

PLEASE NOTE: The Peace Corps does not discriminate based on race, color, religion, sex, national origin, age (over 40), disability, sexual orientation, gender identity, gender expression, marital status, parental status, political affiliation, union membership, genetic information, or history of participation in the EEO process, any grievance procedure, or any authorized complaint procedure. Anyone who feels he or she has been discriminated against should contact the Office of Civil Rights and Diversity, 202.692.2139, ocrd@peacecorps.gov, 1111 20th Street, NW, Washington, DC 20526.

1 Privacy Act Statement Provided via email when the interview is scheduled.

2 Paperwork Reduction Act Statement provided via email when the interview is scheduled.