DD 3067-9 Science, Mathematics, and Research for Transformation (S

Science, Mathematics, and Research for Transformation (SMART) Scholarship
Recruitment Site Visit Request

OMB NO. 0704-0466
OMB approval expires
YYYYMMDD

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 site visit for a SMART Recruitment Awardee.
ROUTINE USES: WWhile 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 Recruitment Awardees are required to complete a Sponsoring Facility (SF) site visit prior to 30 June of the initial award year.
Recruitment Awardees contact their SF Point of Contact (POC) to receive site visit dates. Recruitment Awardees whose address is 50 miles or more from their
SF’s location may be eligible for site visit funding. Site visit funding is a monetary stipend provided to eligible recruitment awardees (eligibility is based on
distance traveled to attend the site visit) to offset some costs associated with traveling for a site visit.

SECTION 1 – Recruitment Awardee Information
Name (Last, First, MI):

Cohort Year:

Phone:

Email:

NEEDS DD67

Degree Level Funded by SMART Program:

BS

BS/MS

MS

PhD Field of Study:

Degree Completion Date (YYYYMMDD):*

Degree Conferral Date (YYYYMMDD):**

*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.

SECTION 2 – Site Visit Information
First Day of Site Visit (YYYYMMDD):

Last Day of Site Visit (YYYYMMDD):
Apartment Number:

Recruitment Awardee Address (location traveling from to attend the site visit):

City:

State:

Zip Code:

State:

Zip Code:

SF:
SF Address:
City:

SECTION 3 – Statement of Understanding
By signing below, I agree that all information provided is true and accurate to the best of my knowledge.
Please Check:
I certify that my address, as listed in Section 2, is the location that I will be traveling from in order to attend the site visit at my SF.
I understand that if I receive compensation to attend a site visit at my SF and I do not attend the site visit, I am required to return all site visit funding to the
SMART Program.
I understand that site visit funding may be provided after eligibility has been determined by the SMART Program, based on the distance I am required to
travel. Site visit funding may or may not be disbursed prior to site visit.
Recruitment Awardee Signature:

DD FORM 3067-9, 20220701 DRAFT

Date Signed (YYYYMMDD):

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Verified distance between recruitment awardee address and SF:
Eligible for site visit funding

Number of miles:

Not eligible for site visit funding

Verified site visit dates with Component Liaison?

Yes

No

Site Visit Report Due Date (YYYYMMDD):
Reviewed by (Name):

Date Reviewed (YYYYMMDD):

NEEDS DD67

DD FORM 3067-9, 20220701 DRAFT

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