Form DD 3067-4 DD 3067-4 Science, Mathematics, and Research for Transformation (S

OMB NO. 0704-0466
OMB approval expires
YYYYMMDD

Science, Mathematics, and Research for Transformation (SMART) Scholarship
Recruitment Internship Report
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C.4093, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 10 U.S.C. 133a, Under Secretary
of Defense for Research and Engineering; DoD Directive 5137.02, Under Secretary of Defense for Research and Engineering (USD(R&E)); DoD Instruction
1025.09, Science, Mathematics, and Research for Transformation Defense Education Program.
PURPOSE: To record a SMART Scholar’s internship experience within 14 days of the conclusion of the internship.
ROUTINE USES: While the information requested on this form is primarily intended to be used internally, in certain circumstances it may be necessary to
disclose this information externally, pursuant to 5 U.S.C. 552a(b)(3), including to contractors, grantees, experts, consultants, students, and others performing or
working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency
function. A complete list of routine uses may be found in the applicable Privacy Act System of Records Notice, DUSDA 14, Science, Mathematics, and Research
for Transformation (SMART) Information management System, found at
https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDA-14.pdf?ver=KO2ZkLWhxB3QCZoRTElMFA%3d%3d
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in SMART scholar being non-compliant with SMART policy, and
subject to possible dismissal.
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, at [email protected]. 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.
INSTRUCTION: All SMART Scholars who have completed an internship must complete and submit an Internship Report no later than 14 days after the
conclusion of the internship.

SECTION 1 – Scholar Information
Name (Last, First, Middle Initial):

Cohort Year:

Phone:

Email:

Sponsoring Component:

Sponsoring Facility (SF):

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Internship Supervisor Name:

Internship Supervisor Email:

SF Mentor Name:

SF Mentor Email:

Internship Start Date (YYYYMMDD):

Internship End Date (YYYYMMDD):

SECTION 2 – Internship Structure and Work Performed

Please type answers in paragraph form using a maximum of 1200 characters/approximately 200 words.
Did your internship start or end date change since your internship request was approved?

Yes

No

If yes, please provide the new dates and reason for the change:

In what ways was your SF prepared for your internship?

Summarize the general work you performed on your own and with your mentor and/or 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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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 sufficient were the internship support payments (if you received internship support payments) in supporting your ability to attend the
internship?

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Are there any aspects of your internship that you would change? If so, please describe them.

Do you have a favorite aspect of or memory from your internship? If so, please describe it.

SECTION 5 – Follow Up
Do you have any issues, comments, or concerns regarding your internship that you would like the SMART Program to contact you about?
Yes

No

If yes, please provide a brief description of the issues, comments, or concerns.

Scholar Signature

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Date Signed (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

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