PEACE CORPS COSTA RICA
Early Termination
Packet
Last review July 2006
\\Server\office\Volunteer Related\COS or ET
documents\DOCUMENTS EARLY TERMINATION
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
CLOSE OF BANK ACCOUNT
This is to acknowledge that I have closed my electronic account No.
at the Banco Nacional de Costa Rica, after I
made sure that all vouchers have been already cleared and paid by the
bank.
Date:
Name:
(Please Print)
(Signature)
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
MEDICAL CLEARANCE FORM
PCV
has been medically cleared by
me on
.
(date)
and has signed the final checklist form on:
date
Peace Corps Medical Officer
(signature)
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
2
PEACE CORPS VOLUNTEER CERTIFICATE
OF NON-INDEBTEDNESS
AND ACCOUNTABILITY FOR PROPERTY
I certify that except as indicated below:
1.
During my Peace Corps service I have not incurred any
indebtedness overseas to any individual or entity
(governmental, commercial, private or otherwise) which I
now have not discharged in full.
2.
I have returned or otherwise accounted for all records and
property of the United States Government or of the
Government and/or entity and/or individual of the country
in which or with whom I have been serving, and for which
property I was responsible.
3.
Exceptions
I hereby authorize Peace Corps to withdraw from my
Readjustment Allowance Account (including U.S. Savings
Bonds held for me) amounts sufficient to discharge the
indebtedness or obligation I list in paragraph 3 above incurred
overseas by me during my Peace Corps service.
Date:
Name:
(Please Print)
(Signature)
Form PC-477 (Rev 11/82)
PCMS 232 Attach A
3
DESIGNATION OF TRAVEL
OPTION 1: Travel to a U.S. Port of Entry
I agree to travel on my Peace Corps "no-fee" passport. I agree to return
my "no-fee" passport and my used air ticket stub to the Transportation
Division (M/AS/T), 1111 20Th Street, Washington, DC 20526, within 14
days of my departure from my host country.
I have received the following from Peace Corps:
A) An air ticket/Government Transportation Request (GTR) for the
cost of my economy class air transportation directly to my home
of record; and
B) A total of
representing
days travel allowance.
I understand that if I fail to return directly and immediately as specified above, or
if I fail to deliver my passport and used ticket stub as specified above, the Peace
Corps may deduct the costs of my economy class air transportation, baggage
and travel allowance advances from my readjustment allowance
___________________________
Signature of Volunteer or Trainee
_______________
Date
___________________________
Signature of Peace Corps Official
_______________
Date
4
ET CHECK OUT SHEET
Name:
_______________________________________________________________
SSN:
______________________________
Date: _________________________
Medical Clearance (Physician):
_____________________________________
Termination report
_____________________________________
(CD or PTO):
Description of service (APCD):
_____________________________________
PC 477 Non Indebtedness (Admin.): _____________________________________
Site equipment clearance (Admin.): _____________________________________
Agreement to return MS284 b (Admin.): _________________________________
Resources (SPA, PCPP, Books, etc):
____________________________________
Confidencial Reason for ET (Admin.): ____________________________________
Received Health Insurance Information (PCV’s sign.) ________________________
Turned in immigration carnet (Admin.): ___________________________________
US Address for final payment: ___________________________________________
___________________________________________
___________________________________________
___________________________________________
TYPE OF TERMINATION
Port of entry
_______________
Resignation ________
Medical
________
Admin. Sep. ________
Field Termination
_______________
Washington Consultation
_______________

Ticket/Travel allowance/Passport received: ___________________
PCV’s signature - Date
5
REQUIRED REPORTS
At present there are two reports that a Volunteer in Costa Rica must write:
1. Description of Service (DOS)
2. Termination Report
DESCRIPTION OF SERVICE
This is an objective document, which serves as the official Peace Corps
reference for former Volunteers. Below you will find answers to the most
common questions regarding the DOS.
A format of the DOS is attached.
Why is the DOS important?
The Description of Service is the only official documentation of what you
have done and accomplished during your PCV service. A copy of the
DOS is the only official information that will be released if you have signed
a release waiver.
What does the DOS include?
The DOS is comprised of three parts: a description of training, a
description of the work and activities performed during service; and a
conclusion statement by the Country Director.
Will the DOS serve as a personal reference for me?
No. The DOS is an objective, factual account of your Peace Corps
service and does not function as a reference. You are encouraged to
make arrangements with your APCD (or other person who is familiar with
your work) to prepare reference letters before your departure date. This
takes time and thought, so the sooner you make arrangements the better.
Who writes the DOS?
You are the ghost writer for the DOS. However, the DOS is written in third
person and is signed bye the Country Director (who will verify that the
information is correct).
May I request a copy of my DOS?
Yes. You will receive the original and a copy will be sent to Washington to
be kept on file for 6 years in the Office of Volunteer Staff and Payroll
Services (VSPS). Copies may be requested by calling the office at
(202)692-1770 Fax (202) 692-1771
6
DOS (Description of Service) Form
for Volunteers on the way out
Instruction Sheet
Following this cover sheet you will find the basic skeleton for your Description of
Service Document. This document will serve as a very useful tool that you can use in
your job search efforts after you return home from Costa Rica. The Country Director will
sign it.
This is an opportunity for you to create a sales tool to sell your skills to potential
employers. Try to think about that purpose as you write. But don't go so far as to start
inventing anything for the content. If the APCD and Country Director don't remember
any of the documented accomplishments or activities that you list, or they are not on
previous work reports the information will probably not make it into the final version.
The DOS should be a MAXIMUM of 2 pages. If your version is more than that it will
be edited to fit into two pages. You should do the editing yourself so that you have the
final say about what stays and what goes. The final two paragraphs in this draft must be
included as a part of those two pages for volunteers who attain COS status. The first two
paragraphs are a standard introduction, which has evolved over time.
Please note where the form requires that enter your NAME, SOCIAL SECURITY NO.,
PROJECT NO., and various DATES. If you are unsure about these, check with your
APCD. Where NAME is requested, you should include your full name in the title block
and in the first mention in the first paragraph. After that use your last name with Mr.,
Ms., Mrs., or whatever appropriate title you prefer.
The most important section is left totally up to you where it says "MORE". In a few
paragraphs you should highlight your most significant activities and accomplishments
during your Peace Corps service. Action verbs and strong, positive statements work best.
The idea is not to go into detail about everything you did, but to emphasize a few
highlights in such a way that the person reading the document will want to meet you to
learn more. In that sense, saying less is often better than saying too much.
It is requested that you submit your DOS to Peace Corps at prior to your departure date in
order to have your official DOS signed and ready. This also permits time for your APCD
and other support staff to revise it and make any and all necessary adjustments to the
document. If it is not submitted on time you may not have the final copy at your
departure date and it will be mailed to you at a later date.
7
Costa Rica
Description of Peace Corps Volunteer Service
Full Name?______? – S.S. No. _______??
Program No. 515-??-??
DESCRIPTION OF TRAINING
After a competitive application process stressing applicant skills, adaptability and cross-cultural
understanding, Mr./Ms. FULL NAME was invited into Peace Corps service in Costa Rica. Mr./Ms. LAST
NAME began Peace Corps Costa Rica’s community-based training program in the town/city of ______on
DATE. The intensive twelve-week training program is designed to help trainees adapt to actual field
situations while living with Costa Rican families. The program included formal instruction in Spanish,
Costa Rican culture, cross-cultural adaptation, community development, non-formal education techniques,
and technical themes related to Community Development and extension activities in Costa Rica. Training
consisted of approximately 150 hours of Spanish language study, 70 hours of technical training in
PROJECT AREA and community extension, and 20 hours of cross-cultural studies. An additional 75 hours
of non-formal self-directed activities were also carried out in technical and cross-cultural themes at the
community level, and an additional 110 hours of field visits with specific objectives in each of the areas
were completed.
Mr./Ms. LASTNAME?______? successfully completed training and was sworn in as a
Volunteer on December 11, 2003 and was assigned to work in PLACE?____?. There
...................WHAT?_____?
MORE???_______??? (About one to one and a half full-pages worth.
Use bullets to separate points.) You may also request a sample
specific DOS from your APCD or PTS.
Pursuant to Section 5(f) of the Peace Corps Act 22 U.S.C. 2504(f), as amended, any former
Volunteer employed by the United States Government following his/her Peace Corps Volunteer
Service is entitled to have any period of satisfactory Peace Corps service credited for purposes of
retirement, seniority, reduction in force, leave and other privileges based on length of Government
service. That service shall not be credited toward completion of the probationary or trial period of
any service requirement for career appointment.
DATE,
San Jose, Costa Rica
Terry Grumley
Country Director
Peace Corps/Costa Rica
8
DOS
DRAFT YOUR DOS USING FORMAT AND YOUR OWN
INFORMATION
REMEMBER: Your DOS is all that the Peace Corps will send
out as an official statement of your Peace Corps experience.
Use Peace Corps Office computers and save it on a disk.
PC will type it into legal Peace Corps jargon.
If you have the document on diskette, give the diskette to the
Country Director
HAVE THE PEACE CORPS DIRECTOR
SIGN THE COMPLETED DOS
PICK UP THE ORIGINAL
IT'S YOURS
A COPY IS SENT TO PC/WASHINGTON
SAMPLE DOS #1
9
TERMINATION REPORT
The second report to be written is called the Termination Report. This report is
for PC/CR's exclusive use and its rational for existence is to provide in-country
staff valuable information for the improvement of Peace Corps' programming,
administration and Volunteer support efforts. Peace Corps asks that when
providing feedback to Post that PCVs also provide specific suggestions for
improvement. The Country Director is the one to receive the Termination
Reports and will use his/her discretion in handling this information. A standard
format does not exist but hopefully your comments will touch on the following
areas:
PRE-SERVICE TRAINING:
Feedback regarding the adequacy for the PC assignments including cultural
information, language training, and development skills.
VOLUNTEER SUPPORT:
Areas which might be included here are in-service training, counseling/emotional
support systems; and/or other areas of support.
ROLE OF THE STAFF:
This area should focus on ways in which staff were involved in the development
and implementation of the program/projects in-country. Suggestions may be
given with regard to what the staff should or should not be doing to support the
Volunteer.
ROLE OF THE VOLUNTEER:
This area should discuss improvements in the way Volunteers approach their PC
assignments and the responsibilities attendant to it.
PC COSTA RICA PROGRAMS:
This area may include comments regarding the general programming effort.
This report, being a subjective document should be written in the spirit of
collaboration. Key to this effort is having information that is useful as feedback,
meaning that it is presented in a way which clearly describes the needed change
and avoids blaming or personal attacks. The report does not have to be typed as
long as your handwriting is legible. When complete please give the report to the
Program Manager or Administrative Officer.
10