SMART Scholarship Site Visit Report for Recruitment Participants

SMART Scholarship-for-Service Program

Site Visit Report for Recruitment Participants

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OMB No.
OMB approval expires

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record site visit feedback required by SMART Recruitment Participants.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C.
1681a(f)) or the Federal Claims Collection Act of 1966 (31 U.S.C. 3701(a)(3)). The purpose of this disclosure is to aid in the collection of outstanding debts owed to the
Federal government, typically to provide an incentive for debtors to repay delinquent Federal government debts by making these debts part of their credit records;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in SMART participant not being compliant with SMART policy and subject
to possible dismissal.

Purpose: A method for SMART Scholarship Recruitment Participants (SSPPs) to provide feedback on their site visit.
Instructions: All recruitment SSPPs who completed a site visit at the Sponsoring Facility (SF) must complete a Site Visit Report no
later than 5 days of the conclusion of the site visit.
SECTION 1 – Participant Information
Name (LAST, First, MI):
Phone:

Cohort Year:
Email:

Sponsoring Service:

Sponsoring Facility (SF):

Supervisor Name:

Supervisor Email:

Site Visit Start Date:

Site Visit End Date:

Please type answers in paragraph form using a maximum of 1200 characters/approximately 200 words.
SECTION 2 – Site Visit Structure
In what ways was your SF prepared for your site visit?

What did you accomplish during the site visit?

Summarize who you were able to meet with at your SF. Was a communication plan established?

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SMART Scholarship-for-Service Program

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SECTION 3 – Ability to Apply Knowledge and Skills
In what ways can your skills or knowledge from your field of study be utilized at you SF?

If you are a graduate student, how will you be able to align your research with your SF’s mission? (Undergraduates, leave blank)

SECTION 4 – Site Visit Funding and Overall Experience
How sufficient was the funding provided in supporting your ability to attend the site visit?

Did your SF provide you with a clear understanding of the mission?

Do you believe you are a good fit with your SF and the mission?

SECTION 5 – Reaffirm Award (initial next to decision)
______ After reviewing all aspects of the facility and my site visit, I determine I am a good fit with the SF and I am reaffirming my decision to
accept the SMART award.
______ After reviewing all aspects of the facility and my site visit, I determine I am not a good fit with the SF and I have chosen to opt out of
the SMART award.
If opting out of the SMART award, please provide any comments regarding your decision in the space below.

a. NAME (Last, First, Middle Initial)

b. SIGNATURE

c. DATE SIGNED (MMDDYYYY)

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Department of Defense, Washington headquarters Services, Executive Services Directorate, Directives Division, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control Number: 0704-0466. Respondents should be aware that notwithstanding any other provisions of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

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