Form OST F 5020.1 OST F 5020.1 Mentor Protégé Program Participant Annual Report

	U.S. Department of Transportation Mentor Protégé Program Participant Annual Report			OMB Control Number: 2105-xxxx Expiration Date: mm/dd/yyyy
Public Burden Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-XXXX. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization (OSDBU) Room W56-312, 1200 New Jersey Ave, SE, Washington, D.C. 20590.
PART A – MENTOR INFORMATION
Business Name		Business Mailing Address (Do not include P.O Box)
Business Physical Address			Phone Number:
Point of Contact:			Email address:
PART B – PROTEGE INFORMATION
Protégé Name			Business Mailing Address (Do not include P.O. Box)
Business Physical Address			Phone Number:
Point of Contact			Email Address:
PART C: PERIOD OF PERFORMANCE
Agreement Period of Performance Start Date: End Date:

Proceed to PART D on page 2.

		U.S. Department of Transportation Mentor Protégé Program Participant Annual Report			OMB Control Number: 2105-xxxx Expiration Date: mm/dd/yyyy
PART D: DEVELOPMENTAL ASSISTANCE
	14 Developmental Task			15 Performed By
16. BUSINESS CAPABILITIES ENHANCED
17. CERTIFICATIONS
18. TECHNOLOGY TRANSFERED
Mentor Signature: Print Name: _________________________________________ Title: ________________________________________________ Signature: ___________________________________________ Date: ___________________			Protégé Signature: Print Name: _________________________________________ Title: ________________________________________________ Signature: ___________________________________________ Date: ___________________
Reviewer’s Signature: Signature: ___________________________________________ Date: ___________________ Print Name: _________________________________________ Title: ________________________________________________

General Instructions

Purpose of Form

Use the Mentor Protégé Annual Report form, OMB Control Number 2105-xxxx, to evaluate the performance of businesses that have entered and finished into a Mentor Protégé agreement in DOT’s Mentor-Protégé program.

How do I Obtain More Information?

You can contact the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization for further information:

Email. [email protected] .

Voice. 1-800-532-1169 or 202-366-1930. A long-distance charge to callers located outside of the local calling area will apply when calling the 202-366-1930 number.

For direct assistance, please contact the OSDBU Filed Office that serves your state. A complete list of FIeld Offices, the states that each region serves, and their contact information is located at http://www.osdbu.dot.gov/regional/index.cfm.

How to submit the Annual Report

You can submit the Mentor Protégé Annual Report to the Director of the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Utilization by email or by fax. Use only one method per submission. Reports must be received within thirty (30) days from the Mentor-Protégé agreement end of year and thirty (30) days from the Mentor Protégé end date.

Email. Scan your signed annual report to a pdf document and email to [email protected].

Fax. Fax your signed report to (202) 366-7228.

Specific Instructions

Print or type all entries on the Mentor-Protégé Annual Report, OMB Control Number 2105-xxxx. The report is an electronically fillable form. We strongly suggest evaluators utilize the electronically fillable form to complete the report. Follow the instructions for each line to expedite processing and to avoid unnecessary requests for additional information.

Line 1. Mentor Name. Enter the business name of the mentor.

Line 2. Business Mailing Address. Enter the mailing address of the mentor’s primary physical location. Do not enter a P.O. Box here.

Line 3. Business Physical Address Enter the physical address of the mentor’s primary physical location.

Line 4. Phone Number: Enter the mentor’s primary phone number.

Line 5. Mentor Point of Contact. Enter the name of the mentor’s primary point of contact for the Mentor-Protégé program.

Line 6. Email Address. Enter the email address of the mentor’s primary point of contact.

Line 7. Protégé Name. Enter the business name of the protégé.

Line 8. Business Mailing Address. Enter the mailing address of the protégé’s primary physical location. Do not enter a P.O. Box here.

Line 9 Business Physical Address Enter the physical address of the protégé’s primary physical location.

Line 10. Phone Number: Enter the mentor’s primary phone number.

Line 11. Protégé Point of Contact. Enter the name of the mentor’s primary point of contact for the Mentor-Protégé program.

Line 12. Email Address. Enter the email address of the mentor’s primary point of contact.

Line 13. Period of Performance. Enter the period of Performance for the report.

Line 14. Developmental Tasks. Provide clear information on the developmental activities performed throughout the period of performance.

Line 15. Performed by. State whether the mentor or the protégé performed the type of activity.

Line 16.Business Capabilities Enhanced. Describe how business capabilities of the protégé were enhanced through the period of performance of the subject agreement.

Line 17. Certifications. Describe the type of certifications received by the protégé through the period of performance of the subject agreement.

Line 18. Technology Transferred. Include in this section if any type of technology was transferred from the mentor to the protégé through the period of performance of the subject agreement.

Line 19. Mentor Signature. Enter name of the person responsible to submit this report from the mentor, include title, signature and date.

Line 20. Protégé Signature. Enter name of the person responsible to submit this report from the mentor, include title, signature and date.

Line 21. Reviewer. For official use only, do not enter any information in this box.

OST F 5020.1 (2-12) Page 2 of 3 OPI:  Office of Small Disadvantaged Business Utilization