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(PC-) Form Number Form Name Office Last Review Date

PC-2113 Applicant Selection / Veteran Passover Form HRM 12.09.13

OHS-HIPAA-APPL-02 Authorization for Peace Corps Use of Medical OHS 1/20005

Information
720A Peace Corps Partnership Program (Telephone OPSI
Donation Form)
OPSI-911.1b Donation Form OPSI
1529 Conditions of Employment with Peace Corps Outside
the Continental U.S. (Initial Appointment Only)

1606 Acknowledge Federal Employees Health Benefits M/HRM

registration form and Federal Employees Group Life
Insurance election form

2075-e Information Technology Procurement Form CIO 2/5/2014

2040 Volunteer Computer Guidelines Signature Form 1/15/2014

2076-e Administrator Account Request Form CIO 1/15/2014

PC-2114 Internal Request for Acting Director or Designee D 12/12/2013
Participation
671A Peace Corps Clearance for Final Payment M/HRM 12/4/2013

840 Peace Corps Authorization of Official Travel 10/31/2013

2073-e Remote Access Services User Agreement Form CIO 10/1/2013

2074-e Permissions to Access Existing Accounts Request CIO 9/1/2013

Form
129 Post/OdyWeb User Access CFO/FS 8/29/2013
718 Odyssey/Prism User Access Form - New User CFO/FS 7/31/2013

626A Peace Corps Annual Performance Plan & Appraisal M/HRM 7/9/2013
Form
2064b Peace Corps Authorization to Use Personal Material D/Comm 6/6/2013

1502 Peace Corps Volunteer Application VRS 5/22/2013

PC-632b Self-Certification Safety Checklist for Teleworkers M/HRM 2/11/2013
Form
2000-e Information Technology Security Media Destruction CIO 2/1/2013
Form
2077 User Agreement Form for Bring Your Own Device CIO/POI/ES 2/1/2013
Program
1540 Procurement Request (PR) 1/1/2013
611-B Intelligence Background Questionnaire D/GC 11/1/2012

719 Odyssey/Prism User Access Form - Modify User CFO/FS 8/29/2012

1723 Peace Corps Volunteer Identification Card 7/10/2012

Information (Privacy Act)
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665 Rights And Responsibilities of Management Officials D/OCRD 6/15/2012

601 Initial Interview Data Sheet D/ADP 5/10/2012

602 Peace Corps Individual Formal Discrimination D/ADP 5/10/2012
Complaint Form
603 Rights and Responsibilities of Complainants D/ADP 5/10/2012
(Employees)
604 Waiver of Anonymity D/ADP 5/10/2012
605 Complainant Designation of Representative D/ADP 5/10/2012

606 Peace Corps Extension of the 30-day EEO Counseling D/ADP 5/10/2012
Period
608 Notice of Withdrawal of EEO Complaint 5/10/2012

656 Request For a Hearing Form D/OCRD 5/10/2012

657 Form to Request a Final Agency Decision or to D/OCRD 5/10/2012
Withdraw the Complaint

660 Employee Notice of Final Interview (NOFI) D/OCRD 5/10/2012

661 Rights & Responsibilities of Complainants D/OCRD 5/10/2012

(Volunteers, Trainees, and Applicants)

663 Volunteer/Trainee/Applicant Notice of Final D/OCRD 5/10/2012

Interview
ADP-958.1.8 Withdrawal of EEO Complaint D/ADP 5/10/2012
1608 US America Peace Corps ID Card SPE 5/10/2012
807 Volunteer Agreement to use U.S. Flag Carriers for M/AS/T 3/21/2012
Return Travel
262-1 Allergy Treatment Form OHS 2/22/2012
262-2 Asthma Evaluation Form OHS 2/22/2012
262-3 Diabetes Diagnosis Form OHS 2/22/2012
262-4 Low Body Mass Index Evaluation Form OHS 2/22/2012

262-5 Disease Diagnosis Evaluation Form OHS 2/22/2012

262-6 Alcohol/Substance Abuse Current Evaluation Form OHS 2/22/2012
(Confidential)
262-7 ECG Form OHS 2/22/2012
262-8 Eating Disorder Treatment Summary Form OHS 2/22/2012
(Confidential)
262-9 Colon Cancer Screening Form OHS 2/22/2012
262-10 Insulin Dependent Diabetic Supplemental OHS 2/22/2012
Documentation Form
262-11 PAP Screening Form (For Female Applicants) OHS 2/22/2012

262-12 Reactive Tuberculin Test Evaluation Form OHS 2/22/2012

TG-510-2 Mental Health Current Evaluation Form OHS 2/22/2012

(Confidential)
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TG-510-3 Mental Health Treatment Summary Form OHS 2/22/2012

(Confidential)
TG-355-2 Mammogram Form OHS 2/12/2012
OHS-2097 Cost-Share Authorization - Yellow Fever VS/OHS 1/19/2012

681B Peace Corps Application for Bicycle Commuter M/AS 12/9/2011

Benefit
2096 Air Freight & DHL Information Survey M/AS/PLS 12/1/2011
1513 U.S. Peace Corps Authorization of Official Travel M/AS/T 11/23/2011
Overseas Assignment
1573 Request and Authorization for Overtime M/HRM/SYS 7/29/2011

2038 Submission Form for Peace Corps Forms 7/19/2011

401A Workplace Access Authorization Form SS/DO/EPPTE 7/17/2011

PC-632 Telework Agreement Form M/HRM 7/5/2011
1532A Confidential Reference Summary 7/1/2011
712 Savings Bond Deductions form Readjustment CFO/VPS 6/14/2011
Allowance
720-F Peace Corps Partnership Program Micro-Grant D/OPSI 6/14/2011
Application Form - $500 and Under

Standard Form 1187 Request for Payroll Deductions for Labor M/HRM 5/17/2011
Organization Dues
0005 National Agency Check Questionnaire for Peace VRS 4/1/2011
Corps Volunteer Background Investigation
680 Report Telework Hours M/HRM 3/24/2011
664-01 Volunteer Activity Approval Form HRM 3/8/2011
1576 Peace Corps Trial Period Certification Report M/HRM 2/7/2011

672 Employee Address Form M/HRM 2/4/2011

505 Mail Services: Customer Satisfaction Survey M/AS/PLS 1/11/2011

10 A Instructions for Requesting Allotments or

Withdrawals from Readjustment Allowance

202 Health Record - Chronological Record of medical OHS

Care
401 Reconciliation of Net Disbursements-Current Month CFO
Appropriated Funds
608A New Employee Orientation (NEO) Evaluation Form

734A Receipt Confirmation For Controlled Substance

DP-969-1 Information about your Peace Corps Service

DP-969.4 Speakers Match Online Request Form D/3GL

DP-969.5 Correspondence Match Educator Online Enrollment D/3GL
Form
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1530 Peace Corps Clearance for Final Payment

1540B Purchase Request Supplemental Report OCFO

1548 Time & Attendance Report

1835a-f PC Digital Library D/Comm
2013 Peace Corps Annual Performance Plan & Appraisal
Form
2017 Request For Expedited Mail Service
2026 Peace Corps Presents this Career Service Certificate
to
2026 Peace Corps Presents this Certificate to

2027 Peace Corps Presents this Certificate of Training

2039 List of Items on Hand and of Transmittals in Transit

2053 Travel Advance Application and Account

2055 Cashier Reimbursement Voucher and/or

Accountability Report
2056 Cashier Reconciliation Statement
2057 General Receipt
2058 Disbursement Cover Sheet
2058B Disbursement Cover Sheet Supplement

2059 Payment Voucher & Receiving Report

2060 Purchase Order
2060B Purchase Order Supplemental Report
Commercial Invoice
PC-2102 DCA Nominee Form OCRD
PC2102a DCA Approval Form OCRD
PC-2103 Records Certification Non-Disclosure Agreement RM

PC-2104 Electronic System Records Inventory RM

PC- 2105 Small Grants Application Form GGM
PC-2106 Small Grants Completion Report GGM
PC-2107 Agreement for Donation of Volunteer Services HRM

PC-2108 Limited Waiver of Confidentiality Form GC

PC-2109 Affidavit Declaring Domestic Partner Relationship VRS

PC-2110 FOR Post/OdyWeb System Administrator (SA) Access CFO/FS

Form
PC-2111 Peace Corps Student/ Intern Exit Checklist HRM
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PC-2112 Global Health Service Partnership PCR Activities OGO

Request and Approval Form