SMART Scholarship Phase 1 Annual Report

SMART Scholarship-for-Service Program

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OMB No.

Phase 1 Annual Report

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 track and project completion of degree requirements, project numbers of internships, project work start date, disclosures, and reports SMART Scholarship
Program Participants achievements and activities.
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.

Awardee Type:
Retention
Recruitment
Instructions: SMART Scholarship Program Participants (SSPPs) complete and submit a Phase 1 Annual Report no later than 1 June each award year during phase 1.
The Phase 1 Annual Report tracks and projects completion of degree requirements, projects number of internships, projects work start date, discloses outside
funding, discloses outside employment, discloses health insurance information, discloses study abroad activities, and reports SSPP achievements and activities. All
information must be typed.

SECTION 1 – Updated Contact Information
Name (LAST, First, MI):
Phone:

Cohort Year:
Email:

Sponsoring Service:

Sponsoring Facility (SF):

SECTION 2 – Academic Information
Academic Institution:
Academic Calendar System:
Semester
Advisor Name:
Date Degree Work Began:
Degree Level Sought:
BA
Graduation Project Requirement:
Required

Quarter

BS
Dissertation

Year Round
Advisor Email:
Degree Title (ex. Computer Science or Electrical Engineering):
BS/MS

MA
Thesis

MS
PhD
Final Project/Report/Paper

No Project

Research/Project Title (if applicable):
Research/Project Summary (if applicable):
Transfer Credits Accepted by University (if applicable):
The ‘Minimum Credits Hours Planned (per term)’ must be equal to or greater than the ‘Number of Credits Required for Full-Time Status (per
term)’ listed below.
Number of Credits Required for Full-Time Status (per term):
Minimum Credit Hours Planned (per term):
The ‘Number of Credits Listed in this Plan’ must be equal to or greater than the ‘Total Credits Required for Degree’ listed below.
Number of Credits Listed in this Plan:
Total Credits Required for Degree:
*

Degree Completion Date :
Notes:

**

Degree Conferral Date :

* Degree completion date - date on which an individual completes all degree requirements. This generally occurs prior to degree conferral and is not set forth on official transcripts.
** Degree conferral date - date on which a degree is bestowed upon an individual. This is set forth on the official transcript reflecting the degree earned and may occur after degree completion.

By signing below I certify that the information contained in this Annual Report is true and correct. A participant’s Phase 1 Annual Report may change during the
course of study.
_________________________________________________
Participant Signature
Date

_________________________________________________
Advisor’s Signature
Date
Page 1 of 8
Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program

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SECTION 3 – Course Listing
Section Instructions:
1.
2.
3.
4.
5.
6.

List courses by term, using one table per term. Start and End Dates = Month and Year
List all courses, past, present, and future through degree completion for the degree funded.
Enter grades for courses already completed.
Note when the summer internships will be completed, if applicable.
For each course, indicate the appropriate requirement code as follows:
R=Required/No Substitution Allowed
P=Prerequisite
ED=Elective Necessary to Meet Degree Requirements
END = Elective NOT Necessary to Meet Degree Requirements
The final Phase 1 Annual Report does not require an advisor’s signature.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Start Date:

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

End Date:
COURSE TITLE

Start Date:

COURSE TITLE

Start Date:

End Date:

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

End Date:
COURSE TITLE

Start Date:

GRADE

End Date:
COURSE TITLE

Start Date:

CREDIT
HOURS

COURSE TITLE

Participant Name ________________________________

End Date:

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

Advisor Initials: _______

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Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Start Date:

COURSE TITLE

Start Date:

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End Date:

Start Date:

COURSE TITLE

COURSE TITLE

Start Date:

End Date:

End Date:

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

End Date:
COURSE TITLE

Start Date:

GRADE

End Date:
COURSE TITLE

Start Date:

CREDIT
HOURS

COURSE TITLE

Participant Name ________________________________

End Date:

Advisor Initials: _______

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Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Start Date:

COURSE TITLE

Start Date:

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End Date:

Start Date:

COURSE TITLE

COURSE TITLE

Start Date:

End Date:

End Date:

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

End Date:
COURSE TITLE

Start Date:

GRADE

End Date:
COURSE TITLE

Start Date:

CREDIT
HOURS

COURSE TITLE

Participant Name ________________________________

End Date:

Advisor Initials: _______

Page 4 of 8
Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Term/Year:
REQUIREMENT
CODE

DEPT/COURSE NO.

Start Date:

COURSE TITLE

Start Date:

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End Date:

Start Date:

COURSE TITLE

COURSE TITLE

Start Date:

End Date:

End Date:

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

CREDIT
HOURS

GRADE

End Date:
COURSE TITLE

Start Date:

GRADE

End Date:
COURSE TITLE

Start Date:

CREDIT
HOURS

COURSE TITLE

Participant Name ________________________________

End Date:

Advisor Initials: _______

Page 5 of 8
Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
SECTION 4 – Health Insurance Information
Did you purchase health insurance for this award year?
YES
Insurance Source:
Academic Institution
Private/Other
Was SMART funding sufficient to cover the insurance cost?
YES
Please state the cost of your health insurance for this award year.

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NO
NO

SECTION 5 – Employment Information
Did you accept employment this award year?
YES
NO
Is the employment with your SF?
YES
NO
Employer Name:
Employer Address and Phone:
Number of Hours per Week:
Dates of Employment:
Description of employment position(s), duties, and reasons employment was accepted:
Description of employment position and duties:
Description of why employment was accepted:

Is the employment with your SF?
YES
NO
Employer Name:
Employer Address and Phone:
Number of Hours per Week:
Dates of Employment:
Description of employment position(s), duties, and reasons employment was accepted:
Description of employment position and duties:
Description of why employment was accepted:

Is the employment with your SF?
YES
NO
Employer Name:
Employer Address and Phone:
Number of Hours per Week:
Dates of Employment:
Description of employment position(s), duties, and reasons employment was accepted:
Description of employment position and duties:
Description of why employment was accepted:

SECTION 6 – Outside Funding Information

Did you accept funding outside of the SMART program this award year?
YES
NO
Funding Source:
Funding Amount Received:
Frequency of Funding (per term/per year):
Description of why outside funding was accepted:

Funding Source:
Funding Amount Received:
Description of why outside funding was accepted:

Frequency of Funding (per term/per year):

Page 6 of 8
Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
Funding Source:
Funding Amount Received:
Description of why outside funding was accepted:

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Frequency of Funding (per term/per year):

SECTION 7 – Academic Interest

Provide a one-line synopsis of your topic of academic interest: (ex: Computer Science with an emphasis on artificial intelligence and cognitive
science)
Summarize the reason for your pursuit of the above topic of interest: (provide answer in paragraph form using a maximum of 1200
characters/approximately 200 words)

SECTION 8 – Professional and Academic Goals

Discuss how your academic and professional goals relate to the mission of your SF. If you are a graduate level participant and your
thesis/dissertation research is aligned with the work being done at your SF, please discuss: (provide answer in paragraph form using a
maximum of 1200 characters/approximately 200 words)

Discuss how SMART is helping you achieve your academic and professional goals: (provide answer in paragraph form using a maximum of
1200 characters/approximately 200 words)

SECTION 9 – Foreign Travel
Did you participate in any foreign travel this past year?
YES
NO
Location of Foreign Travel:
Dates of foreign travel
Date of Return:
Did you participate in a study abroad program this award year?
YES
NO
Location of Study-Abroad Program:
Dates of Study-Abroad Program:
Academic Credits Earned from Study-Abroad Program:
Description of why the study-abroad is beneficial to your degree pursuit:

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Phase 1 Annual Report, revised 2015

SMART Scholarship-for-Service Program
SECTION 10 – Accomplishments
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Type of Accomplishment:

Community Service

Honors/Recognition

Patent

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Date:
Presentation

Publication

Research

Other

Publication

Research

Other

Publication

Research

Other

Publication

Research

Other

Publication

Research

Other

Summary of Accomplishment:

Accomplishment Title:
Type of Accomplishment:

Date:
Community Service

Honors/Recognition

Patent

Presentation

Summary of Accomplishment:

Accomplishment Title:
Type of Accomplishment:

Date:
Community Service

Honors/Recognition

Patent

Presentation

Summary of Accomplishment:

Accomplishment Title:
Type of Accomplishment:

Date:
Community Service

Honors/Recognition

Patent

Presentation

Summary of Accomplishment:

Accomplishment Title:
Type of Accomplishment:

Date:
Community Service

Honors/Recognition

Patent

Presentation

Summary of Accomplishment:

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 4 hours 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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Phase 1 Annual Report, revised 2015