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Science, Mathematics, and Research for Transformation (SMART) Scholarship
Phase 1 Annual 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 track academic progress, project completion of degree requirements, and to gather SMART Scholar achievements, activities, and other
disclosures necessary for ensuring successful progress and completion of SMART Scholarship requirements.
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, or, to academic institutions for the purposes of providing progress reports for applicants and participants. 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 2 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, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. 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.
Award Type:
Recruitment
Retention
Retention - Retention scholars are individuals who are employed in a full-time permanent or renewable term civilian position by the sponsoring facility at the time
of award.
Recruitment - Recruitment scholars are individuals who are not employed in a full-time permanent or renewable term civilian position by the sponsoring facility at
the time of award.
Cohort - A "cohort" refers to the group of the participants who received a SMART award in a particular year. For example, participants who received a SMART
award in 2021 are part of the 2021 cohort.
NEEDS DD67
INSTRUCTIONS: SMART Scholars 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 academic progress, project completion of degree requirements, and to gather SMART Scholar achievements, activities, and other disclosures
necessary for ensuring successful progress and completion of SMART Scholarship requirements.
SECTION 1 – Awardee Information
Name (Last, First, Middle Initial):
Cohort Year:
Phone:
Email:
Sponsoring Component:
Sponsoring Facility (SF):
SECTION 2 – Academic Information
Academic Institution:
Academic Calendar System:
Semester
Quarter
Year-Round
Advisor Name:
Advisor Email:
Date Degree Work Began (YYYYMMDD):
Field of Study (ex. Computer Science, Electrical Engineering, etc.)
Approved Degree Level to be Pursued:
BS
Graduation Project (Response Required):
BS/MS
Dissertation
MS
Thesis
PhD
Final Project/Report/Paper
No Project Required
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):
DD FORM 3067-7, 20220701 DRAFT
Minimum Credit Hours Planned (per term):
Page 1 of 10
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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 (YYYYMMDD):*
Degree Conferral Date (YYYYMMDD):**
Notes: *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 scholar’s Phase 1 Annual Report responses may
change during the course of study.
Scholar Signature:
Advisor Signature:
Date (YYYYMMDD):
Date (YYYYMMDD):
SECTION 3 – Course Listing
1. List courses by term, using one table per term. Start and End Dates = Month and Year
2. List all courses, past, present, and future through degree completion for the degree funded.
3. Enter grades for courses already completed.
4. Recruitment Awardees: Note when each summer internship will be completed.
5. For each course, indicate the appropriate requirement code as follows:
R=Required/No Substitution Allowed
ED=Elective Necessary to Meet Degree Requirements
P=Prerequisite
END = Elective NOT Necessary to Meet Degree Requirements
6. The final Phase 1 Annual Report does not require an advisor's signature.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
Term/Year:
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
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PREVIOUS EDITION IS OBSOLETE.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
Term/Year:
COURSE TITLE
Start Date (YYYYMMDD):
REQUIREMENT CODE
Term/Year:
End Date (YYYYMMDD):
DEPT/COURSE NO.
CREDIT HOURS
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
Term/Year:
REQUIREMENT CODE
COURSE TITLE
CREDIT HOURS
GRADE
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
End Date (YYYYMMDD):
Start Date (YYYYMMDD):
DEPT/COURSE NO.
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
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PREVIOUS EDITION IS OBSOLETE.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
Term/Year:
COURSE TITLE
Start Date (YYYYMMDD):
REQUIREMENT CODE
Term/Year:
End Date (YYYYMMDD):
DEPT/COURSE NO.
CREDIT HOURS
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
Term/Year:
REQUIREMENT CODE
COURSE TITLE
CREDIT HOURS
GRADE
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
End Date (YYYYMMDD):
Start Date (YYYYMMDD):
DEPT/COURSE NO.
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
Page 4 of 10
PREVIOUS EDITION IS OBSOLETE.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
Term/Year:
COURSE TITLE
Start Date (YYYYMMDD):
REQUIREMENT CODE
Term/Year:
End Date (YYYYMMDD):
DEPT/COURSE NO.
CREDIT HOURS
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
Term/Year:
REQUIREMENT CODE
COURSE TITLE
CREDIT HOURS
GRADE
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
End Date (YYYYMMDD):
Start Date (YYYYMMDD):
DEPT/COURSE NO.
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
Page 5 of 10
PREVIOUS EDITION IS OBSOLETE.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
Term/Year:
COURSE TITLE
Start Date (YYYYMMDD):
REQUIREMENT CODE
Term/Year:
End Date (YYYYMMDD):
DEPT/COURSE NO.
CREDIT HOURS
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
Term/Year:
REQUIREMENT CODE
COURSE TITLE
CREDIT HOURS
GRADE
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
End Date (YYYYMMDD):
Start Date (YYYYMMDD):
DEPT/COURSE NO.
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
Page 6 of 10
PREVIOUS EDITION IS OBSOLETE.
Term/Year:
Start Date (YYYYMMDD):
REQUIREMENT CODE
DEPT/COURSE NO.
Term/Year:
COURSE TITLE
Start Date (YYYYMMDD):
REQUIREMENT CODE
Term/Year:
End Date (YYYYMMDD):
DEPT/COURSE NO.
CREDIT HOURS
End Date (YYYYMMDD):
COURSE TITLE
CREDIT HOURS
NEEDS DD67
REQUIREMENT CODE
Start Date (YYYYMMDD):
DEPT/COURSE NO.
Term/Year:
REQUIREMENT CODE
COURSE TITLE
CREDIT HOURS
GRADE
End Date (YYYYMMDD):
COURSE TITLE
Scholar Initials:
DD FORM 3067-7, 20220701 DRAFT
GRADE
End Date (YYYYMMDD):
Start Date (YYYYMMDD):
DEPT/COURSE NO.
GRADE
CREDIT HOURS
GRADE
Advisor Initials:
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SECTION 4 – Health Insurance Information
Did you purchase health insurance for this award year?
Yes
Insurance Source:
Academic Institution
No
Was SMART funding sufficient to cover the insurance cost?
Yes
Private/Other
No
Please state the cost of your health insurance for this award year.
SECTION 5 – Outside Employment Information (Not including an internship with approved Sponsoring Facility)
Did you accept outside employment this award year?
Yes
No
Is the employment federally funded (e.g., directly with federal agency, with an organization
that is funded by the federal government, etc.)?
Yes
No
Employer Name:
Employer Address:
Suite Number:
City:
State:
Phone Number:
Zip Code:
Number of Hours per Week:
Description of Outside Employment Position and Duties:
Dates of Outside Employment:
Description of Why Outside Employment was Accepted:
NEEDS DD67
Is the employment federally funded (e.g., directly with federal agency, with an organization
that is funded by the federal government, etc.)?
Employer Name:
Employer Address:
No
Suite Number:
City:
Phone Number:
Yes
State:
Zip Code:
Number of Hours per Week:
Description of Outside Employment Position and Duties:
Dates of Outside Employment:
Description of Why Outside Employment was Accepted:
Is the employment federally funded (e.g., directly with federal agency, with an organization
that is funded by the federal government, etc.)?
Yes
No
Employer Name:
Employer Address:
Suite Number:
City:
Phone Number:
State:
Number of Hours per Week:
Description of Outside Employment Position and Duties:
DD FORM 3067-7, 20220701 DRAFT
Zip Code:
Dates of Outside Employment:
Description of Why Outside Employment was Accepted:
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SECTION 6 – Outside Funding Information
Did you accept outside funding this award year?
Yes
No
Funding Source:
Funding Amount Received:
Frequency of Funding (per term/per year):
Description of why outside funding was accepted:
Did you accept outside funding this award year?
Yes
No
Funding Source:
Funding Amount Received:
Frequency of Funding (per term/per year):
Description of why outside funding was accepted:
Did you accept outside funding this award year?
Yes
No
Funding Source:
Funding Amount Received:
Frequency of Funding (per term/per year):
Description of why outside funding was accepted:
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).
NEEDS DD67
Summarize the reason for your pursuit of the above topic of interest and its applicability to your SF’s mission (Provide answer in paragraph form using a
minimum of 450 characters/approximately 75 words and 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 scholar, and your
thesis/dissertation research is aligned with the work being done at your SF, please discuss (Provide answer in paragraph form using a minimum of 600
characters/100 words and a maximum of 1200 characters/approximately 200 words).
Discuss how The SMART Program is helping you achieve your academic and professional goals (Provide answer in paragraph form using a minimum of
600 characters/approximately 100 words and a maximum of 1200 characters/approximately 200 words).
DD FORM 3067-7, 20220701 DRAFT
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SECTION 9 – Foreign Travel/Study Abroad*
*Note: all scholars must notify their SF POC and respective SF security manager at least 30 days prior to foreign travel.
Did you participate in any foreign travel this past year?
Yes
No
Location(s) of foreign travel:
Date(s) of foreign travel:
Date(s) of Return:
Did you participate in a study abroad program this award year?
Yes
No
Location(s) of Study-Abroad Program:
Date(s) of Study-Abroad Program:
Academic Credits Earned from Study-Abroad Program:
Description of why the study-abroad is beneficial to your degree pursuit:
SECTION 10 – Accomplishments
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Date (YYYYMMDD):
Type of Accomplishment:
Community Service
Honors/Recognition
Patent
Presentation
Publication
Research
Other
Research
Other
Research
Other
Research
Other
Research
Other
Research
Other
Summary of Accomplishment:
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Date (YYYYMMDD):
Type of Accomplishment:
Community Service
Honors/Recognition
Patent
Presentation
Publication
NEEDS DD67
Summary of Accomplishment:
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Type of Accomplishment:
Date (YYYYMMDD):
Community Service
Honors/Recognition
Patent
Presentation
Publication
Summary of Accomplishment:
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Type of Accomplishment:
Date (YYYYMMDD):
Community Service
Honors/Recognition
Patent
Presentation
Publication
Summary of Accomplishment:
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Type of Accomplishment:
Date (YYYYMMDD):
Community Service
Honors/Recognition
Patent
Presentation
Publication
Summary of Accomplishment:
Section Instructions: List accomplishments you have achieved during this award year.
Accomplishment Title:
Type of Accomplishment:
Date (YYYYMMDD):
Community Service
Honors/Recognition
Patent
Presentation
Publication
Summary of Accomplishment:
DD FORM 3067-7, 20220701 DRAFT
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PREVIOUS EDITION IS OBSOLETE.
| File Type | application/pdf |
| File Title | DD Form 3067-7, "Science, Mathematics, and Research for Transformation (SMART) Scholarship Phase 1 Annual Report " |
| File Modified | 2022-07-01 |
| File Created | 2022-06-29 |