Form CD-593 U.S. DOC National Environmental Policy Act Environmental

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CD-593
(11-09)

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Proposed Project Name: ___________________________
Proposing Institution or Entity: ______________________________
Project Description:
(Briefly describe or attach synopsis of proposal):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Amount of Project ($): ___________________________
Contact information for person completing the checklist:
Name: ________________________________________
Phone Number: ________________________________________
Organization: ________________________________________
The Department of Commerce’s (DOC) Administrative Order implementing the National
Environmental Policy Act (NEPA) of 1969, (as amended), require environmental data or
documentation to assist DOC in carrying out its responsibilities under NEPA. Therefore,
it is necessary for the applicant to provide DOC with sufficient information concerning
their proposed activity. Based on an environmental evaluation conducted at the project
proposal phase, DOC will determine the appropriate level of environmental review. DOC
will determine whether an environmental assessment or an environmental impact
statement is necessary for the proposed activity or whether the activity can be
categorically excluded from additional NEPA review.

DOC Environmental Questionnaire & Checklist

Page 1 of 15

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Instructions:
The checklist is divided into two sections. Section 1 is for those projects that have
historically shown no adverse impacts to the human or natural environment. These
projects consist solely of administrative actions, personnel activities, or minor
procurement activities. Grants involving the purchase of computers or software going
into existing facilities; issuance of fellowships, training or meeting facilitation in existing
structures; printing of informational materials or brochures; the hiring of Census takers;
and minor interior renovations are suggested to use this section. If the project falls into
the one of the categories listed in Section 1, then you do not need to complete Section
2.
Section 2 is for those projects requiring ground disturbance of any kind, building of
facilities, installations, or structures; and any project with the potential to significantly
impact the human or natural environment.
For Section 2, complete the following checklists based upon your knowledge of the
proposed project site and immediate vicinity. If you are “unable to determine” the
potential effect on a described resource, efforts should be undertaken to acquire
available information on the resource or the effect of the project on the resource. If the
proposal is determined to have an effect (checked “yes”) or the preparer is unable to
determine if the proposal will have an effect (checked “unable to determine”), the project
might be subject to further environmental review, not withstanding other determinations
under state environmental review laws and regulations.
If the proposal is determined to have no environmental effect (checked “no”), the project
may qualify for a categorical exclusion (CE) from further environmental review. DOC is
ultimately responsible for determining if the proposal qualifies for a CE. If all elements
of the proposed project do not conform to the identified CE’s (published in the Federal
Register on July 10, 2009), an Environmental Assessment (EA) or an Environmental
Impact Statement (EIS) may be required prior to funding and/or initiation of the project.
Prior environmental reviews may satisfy EA/EIS requirements. Enclose copies of
environmental review reports, including decision documents and evidence of public
involvement with this form.

DOC Environmental Questionnaire & Checklist

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U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Submit this completed form to:
__________________________________
__________________________________
__________________________________
__________________________________
NOTES:


Additional sheets may be used to explain responses to specific questions.



DOC may request additional information.

DOC Environmental Questionnaire & Checklist

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U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

SECTION 1
To be completed for those projects historically shown to not create significant
environmental impacts to the human or natural environment. Any answer of
“No” or “Unknown” may require additional documentation or review.

Question

Yes

1. Is the proposed action solely a procurement action for materials
intended to be installed, stored or operated in an existing building
or structure?
2. If the proposed action involves procurement of electronic
equipment, will the equipment be disposed of in an environmentally
sound manner at the end of its’ useful life?
3. Does the proposed action consist solely of personnel actions
intended for Census activities?
4. Does the proposed action involve only minor interior renovations to
a structure, facility, or installation?
5. Is the proposed action solely for the production and/or distribution
of informational materials, brochures, or newsletters?
6. Does the proposed action encompass only literature surveys,
inventories, data analysis, or audits?
7. Does the proposed action only involve the granting of fellowships?
8. Does the proposed action consist solely of training, teaching, or
meeting facilitation at an existing facility or structure?

DOC Environmental Questionnaire & Checklist

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No

Unknown

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

SECTION 2
To be completed for those projects involving ground disturbance or potential to
significantly impact the human or natural environment. Please answer the
following questions:
1. Are the personnel preparing this form familiar with the site?
_____________________________________________
2. List the names of those who conducted the site visit(s):
_____________________________________________
3. List the date(s) of the site visit(s):
_____________________________________________
4. Has consultation with all affected agencies or tribes been completed?
_____________________________________________
5. Provide a description of all the coordination with other agencies and affected
Indian tribes incorporated into planning this project and evaluating possible
environmental impacts (or attach equivalent information. If none, so state):

Description of agency/tribal contact

DOC Environmental Questionnaire & Checklist

Date

Description of
attendees/
recipients

Page 5 of 15

Location

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

6. Provide a description of all the public involvement incorporated into planning this
project and evaluating possible environmental impacts (or attach equivalent
information. If none, so state):

Name of Event/meeting or public
involvement measure

Date

Description
of
attendees/
recipients

.

DOC Environmental Questionnaire & Checklist

Page 6 of 15

Location

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist
7. Please answer all of the questions in the following checklist. If you need additional space to respond, please attach
an additional sheet of paper to this document

Question

Yes

1. Is the proposed project part of a larger scope of work?
a. If yes, please describe.

2. Do you anticipate requesting additional federal funding for subsequent
phases of this proposed action?
a. If yes, please describe.

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

3. Does this proposed action have the potential to be controversial because
of disagreement over possible environmental, cultural, or historical
resources?
a. If yes, please explain.

4. Does this proposed action have the potential for significant impact as
indicated by a federal, state, or local agency or Indian tribe?

5. Has any environmental review (e.g., NEPA documentation, permit,
historic preservation consultation) been completed for this proposed
action?
a. If yes, please attach a copy of the document to this checklist.

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Yes

Question

6. If the property includes a real estate acquisition or lease, has an
Environmental Due Diligence Audit been completed?
a. If yes, please attach a copy of the document to this checklist.

7. Will the proposed action have the potential to impact wetlands,
floodplains, coastal zones, or forest conservation areas?
8. Is the proposed action directly related to other actions with individually
insignificant, but cumulatively significant, environmental effects?
9. Will the proposed action have uncertain environmental effects?
10. Will the proposed action have the potential to impact species listed or
proposed to be listed on the List of Endangered or Threatened Species, or
have adverse effects on designated Critical Habitat for these species?

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

11. Will the proposed action establish a precedent for future action or
represent a decision in principle about future actions with potentially
significant environmental effects?
12. Is the proposed action likely to adversely affect a significant aspect of the
natural environment?
a. Affect the water supplies of humans, animals, or plants;
b. Affect the water table; or
c. Involve construction or use of a facility on or near an active
geological fault.
13. Does the proposed action contribute to the introduction, continued
existence, or spread of non-native invasive species or actions that may
promote the introduction, growth or expansion of the range of non-native
invasive species (EO 13112)?
14. Does the project involve the generation of ionizing or non-ionizing
radiation or use of any radiation source?

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

15. Does the proposed action involve construction on or near an active or
abandoned toxic, hazardous or radioactive materials generation, storage,
transportation, or disposal site.
a. If yes, will this require new or amended permits or approvals?
16. Will the proposed action involve storage or release of water
contaminants (thermal, sediments, oxygen-depleting chemicals, pesticides,
fertilizers, substances hazardous to human health, etc.) in amounts greater
than allowed in currently existing permits?
17. Will the proposed action involve production, storage, transportation, or
disposal of large amounts of solid waste in excess of local waste disposal
facility capacity?
18. Will the proposed action involve use of a site that contains underground
storage tanks (USTs)?
19. Will the proposed action involve use or release of ozone-depleting
chemicals?
20. Will the proposed action involve emission of light or lasers exceeding
established standards for persons or animals or affecting surrounding land
and airspace uses (such as airports & astronomical observatories)?

DOC Environmental Questionnaire & Checklist

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No

Unable to
Determine

Need More
Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

21. Will the proposed action involve emission of high levels of noise
exceeding local noise ordinance levels?
22. Does the proposed action involve the use of sonars or other underwater
sound propagation devices?
23. Will the proposed action have disproportionate and adverse effects on
the health or environmental risk of different population segments, such as
children, the elderly, those with handicapping conditions, low income
populations, or minorities?
24. Will the proposed action have an ongoing pattern of pollutant discharge;
traffic generation, patterns, or volumes; economic change, or land-use
change in its locality that could collectively affect human health or the
condition of the environment?
25. Will the proposed action have the potential to affect historic,
archeological, or cultural sites, including Native American burial or
ceremonial grounds?
26. Will the proposed action involve a known archeological site, or land
identified by archeologists as having high potential to contain archeological
resources?

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

27. Will the proposed action take place on property under the auspices of
the National Capital Planning Commission?
28. Will the proposed action have a disproportionate, significant adverse
effect on low-income or minority populations (EO 12898)?
29. Will the proposed action restrict access to and ceremonial use of Indian
sacred sites by Indian practitioners or adversely affect the physical integrity
of such religious sacred sites (EO 13007)?
30. Will the proposed action have adverse effects on properties listed or
eligible for listing on the National Register of Historic Places?
31. Will the proposed action change the use of park lands?
32. Will the proposed action threaten to violate a federal, state, local, or tribal
law or requirements imposed for the protection of the environment?

DOC Environmental Questionnaire & Checklist

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No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

Question

Yes

33. Will the proposed action require a permit from a federal, state, or local
agency to proceed, unless the agency from which the permit is required
agrees that a CE is appropriate?
34. Will the proposed action require, in any part, review or permitting by any
other federal, state, regional, local, environmental, or regulatory agency?
a. If yes, please list name of agency and type or review or permit
needed.
35. Will the proposed action affect a State's Coastal Zone Management
Plan?
36. Will the proposed action violate Occupational Health and Safety
Administration (OSHA) standards?

DOC Environmental Questionnaire & Checklist

Page 14 of 15

No

Unable to Need More
Determine Information

U.S. Department of Commerce
National Environmental Policy Act (NEPA)
Environmental Questionnaire & Checklist

8. Please describe any other aspects of he proposed action that could potentially affect the human or natural environment. Use
a separate sheet if necessary.

Certification
(insert Disclaimer and Statute here…)

Project Name:
________________________________________________
Proposing Institution: ________________________________________________
Organizational Entity: ________________________________________________
Signing Official:
________________________________________________
Date: _____________________
___________________________

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Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act (PRA), unless
that collection displays a currently valid Office of Management and Budget (OMB) control number.

DOC Environmental Questionnaire & Checklist

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