SMART Scholarship Foreign Travel Notification

SMART Scholarship-for-Service Program

20___
OMB No.

Foreign Travel Notification

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 document a SMART Participant’s foreign travel.
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.
Instruction. Foreign travel is any travel outside the United States, its Territories or Possessions. Foreign travel may affect eligibility to obtain and maintain a security
clearance. SMART Scholarship Program Participants (SSPPs) notify the SMART Security Specialist before traveling to a foreign country.
SECTION 1 – Participant Information
Date Submitted (Month/Day/Year):
Name (LAST, First, MI):
Phone:

Cohort Year:
Email:

SECTION 2 – Countries to be Visited
List countries you will be spending significant time in. Do not list countries you are traveling through.

SECTION 3 –Travel Information
Departure: (Month/Day/Year)
Departure Airline(s):

Return: (Month/Day/Year)
Return Airline(s):

Departure Number(s):

Return Number(s):

SECTION 4 – Lodging Information
Name of Hotel or Friend/Family Member you are staying with:
Address(s):

Phone:
SECTION 5 – Impact/Requirement Information
Reason for Travel:

SECTION 6 – Emergency Point of Contact
Name:
Phone:

Relationship:
Email:

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 30 minutes 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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Foreign Travel Notification, revised 2015