SMART Scholarship Internship Report for Recruitment Participants

SMART Scholarship-for-Service Program

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OMB No.

Internship Report for Recruitment Participants

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 a SMART Participant’s internship experience within 14 days of the conclusion of the internship.
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.

Instructions: All multi-year recruitment participants who completed an internship must complete and submit an Internship Report
no later than 14 days of the conclusion of the internship.
SECTION 1 – Participant Information
Name (LAST, First, MI):
Phone:

Cohort Year:
Email:

Sponsoring Service:

Sponsoring Facility (SF):

Supervisor Name:

Supervisor Email:

Mentor Name:

Mentor Email:

Internship Start Date:

Internship End Date:

Please type answers in paragraph form using a maximum of 1200 characters/approximately 200 words.
SECTION 2 – Internship Structure and Work Performed
In what ways was your SF prepared for your internship?

Summarize the general work you performed on your own and with your mentor/supervisor during the internship.

When you begin working for your SF, how will your duties be different from your internship duties?

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Internship Report- SSPP, revised 2015

SMART Scholarship-for-Service Program

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SECTION 3 – Ability to Apply Knowledge and Skills
What skills or knowledge from your field of study were utilized during your internship?

In what ways were your professional skills expanded during your internship?

SECTION 4– Internship Support Payments and Overall Experience
How sufficent were the internship support payments in supporting your ability to attend the internship?

Describe one aspect of your internship you would change.

Describe your favorite moment or aspect of your internship.

SECTION 5 – Follow Up
Would you like your Cohort Administrator (CA) to contact you about any issues/comments/concerns regarding your
internship?

Participant Signature: __________________________________________

Yes

No

Date: __________________

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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