Form 1 0324 - Environmental Checklist

OMB No.: 0915-0324 Expiration Date: XX/XX/XXXX

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

ENVIRONMENTAL INFORMATION AND DOCUMENTATION (EID)

FOR HRSA USE ONLY

Award Recipient Name

Award Number

Application Tracking #

Project #

Project Type

Project Title

This Environmental Information and Documentation (EID) checklist consists of information that the agency is required to obtain to comply with the National Environmental Policy Act of 1969 (NEPA). NEPA establishes the Federal government's national policy for protection of the environment. HRSA has developed the EID for applicants of funding that would potentially impact the environment and to ensure that their decision-making processes are consistent with NEPA. Applicants must provide information and requested on the EID checklist so that HRSA may ensure compliance with NEPA.

HRSA will provide applicants with the results of the agency's environmental review through the NGA. If HRSA determines that additional environmental compliance is necessary, HRSA will notify applicable Award Recipients of specific requirements.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0324. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, 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 this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

Award Recipient Authorized Official:
Phone:
Email:

Award Recipient EID Preparer:
Phone:
Email
Address:

Project Location/Address (Please note - separate EID forms are required for each project location)
Please provide the address where the action will occur (e.g. where equipment will be located or where renovations/new construction will occur)

Scope of work
Describe all actions that are part of the proposed action (Please include a description of the entire project, including elements that will use non-federal funding)

Site Description - required for all building renovations (e.g. interior renovations, new windows, roofs, etc.) and new construction (including building additions, temporary facilities, and trailers)

Site acreage:

Land use on site:

Land use surrounding site (current use, zoning and proposed changes if applicable):

Buildings currently on site (stories, height, age, total sq. footage):

Vegetation on site (e.g. grasses, shrub, heavily wooded, none because it's paved, etc.):

Streams/wetlands on site or adjacent to the site:

Proposed ground disturbance (sq. footage):

A. Scope of Proposed Action

This set of questions is concerned with size and scope of the proposed action

A.1. Will the action involve the purchase, construction or lease of new facilities (including temporary facilities and trailers), or substantially increase the capacity of an existing health care facility?
[_] Yes [_] No

If yes explain:

A.2. Is the action significantly greater in scope than other development taking place in the area, or will it have significant unusual characteristics?
[_] Yes [_] No

If yes explain:

B. Potential for Public Controversy

This set of questions is concerned with whether or not the proposed action has or could generate public controversy.

B.1. Are there any public concerns or controversy with respect to effects of the action on environmental or cultural resources based on reasonable and substantial issues?
[_] Yes [_] No

B.2. Have comments on the action's impacts to environmental or cultural resources been received from the public or from local, State, or Federal agencies?
[_] Yes [_] No

If yes explain:

C. Degradation of Environmental Conditions

This set of questions concerns the potential for actions to degrade, even slightly, already existing poor environmental conditions.

C.1. Will the action increase identifiable ambient air pollution levels from a new emission source or from existing sources (e.g., lab fume hoods, HVAC systems, etc.)?
[_] Yes [_] No

If yes explain:

C.2. Will the action increase identifiable ambient air pollution levels through a major increase in the number of or use of automobiles, trucks (e.g., will there be a large number of new employees or patients traveling to the site, or a large number of deliveries to the site?
[_] Yes [_] No

C.3. Will the action exceed city or State health or Federal air quality standards with exhausts from fume hoods
[_] Yes [_] No

If yes explain:

C.4. Will the action cause or increase soil erosion?
[_] Yes [_] No

If yes explain(For building additions and/or new construction, please list measures to be taken to control sedimentation and soil erosion):

C.5. Will the action discharge stormwater or pollutants into a stream, river, lake, etc.?
[_] Yes [_] No

If yes explain(For building additions and/or new construction, please note any stormwater management practices to be utilized):

C.6. Will the action overload existing waste treatment plants due to new loads (water volume, chemicals, toxicity, etc.)?
[_] Yes [_] No

If yes, please obtain and submit a connection permit or other approval from local sewer authority.

C.7. Will the action allow seepage of contaminants into the water table?
[_] Yes [_] No

If yes explain:

D. New or Unproven Technology

This set of questions is concerned with the deployment of new or unproven technology with the potential adverse effects or actions involving unique or unknown environmental risks

D.1. Will the action involve the purchase or use of new or unproven technology?
[_] Yes [_] No

If yes explain:

D.2. Will the action involve the purchase or use of technology for which the environmental impacts are unknown?
[_] Yes [_] No

If yes explain:

E. Presence of cultural, archaeological, historical or other protected resources

This set of questions is concerned with potential impacts to cultural resources including, but not limited to, buildings; archaeological sites; National Historic Landmarks; objects of significance to a Native American Tribe including graves, funerary objects, and traditional cultural properties; or other protected resources. HRSA will provide applicants with the results of the agency's historic preservation assessment through the Notice of Award Award (NGA). If HRSA determines that additional review by the State Historic Preservation Office (SHPO) is necessary, HRSA will instruct applicable Award Recipients on how to initiate consultation with the SHPO.

E.1. Will the action involve the purchase, construction, alteration, renovation, or lease of real property or portion of real property?
[_] Yes [_] No

If yes, when was the building constructed?

E.2. Will the proposed action occur in or near a building listed on or eligible for listing on the National Register of Historic Places?
[_] Yes [_] No

E.3. Will the proposed action adversely affect properties listed on or eligible for listing on the National Register of Historic Places?
[_] Yes [_] No

If yes explain:

E.4. Will the action encroach upon, change views to, or change noise levels around any historical, architectural, or archeological cultural property?
[_] Yes [_] No

If yes explain:

F. Protected Species

This set of questions is concerned with protected plant and animals, including endangered or threatened species or their critical habitat.

F.1. Will the action be likely to adversely affect a plant or animal species listed on the Federal or applicable State list of endangered or threatened species or a specific critical habitat of an endangered or threatened species?
For assistance, contact the appropriate State Fish and Wildlife Agency or the regional office of the U.S. Fish and Wildlife Service.
[_] Yes [_] No

If yes explain:

F.2. Will the action adversely affect nesting Bald Eagles or migratory birds?
[_] Yes [_] No

If yes explain:

G. Special Status Areas and Critical Resources

These questions are concerned with actions with the potential to adversely affect special status areas or other critical resources such as wetlands, floodplains, coastal zones, wildlife refuge and wilderness areas, wild and scenic rivers, or sole or principal drinking water aquifers.

G.1. Are there wetlands or waters of the U.S. on or adjacent to the site?
[_] Yes [_] No

If yes, attach National Wetland Inventory Map, State or local map, or site specific map

G.2. Will the action include discharge to or the filling or dredging of wetlands?
[_] Yes [_] No

If yes explain:

G.3. Will the action require a section 404 (Clean Water Act) permit for actions in a wetland and/or section 10 (Rivers and Harbors Act) permit for actions in a stream or river? (Activities in or near a wetland or river may require a permit from the U.S. Army Corps of Engineers or U.S. Coast Guard. Includes: construction in or near any wet or dry waterway, stream crossings, intake structures, outfalls, etc.)
[_] Yes [_] No

If yes, provide status of permit process:

G.4. Is the project site located in either a 100-year or a 500-year floodplain?
[_] Yes [_] No

Regardless of whether the project is in a known floodplain, please attach a Flood Insurance Rate Map to this document. Clearly mark the location of the facility, and the NFIP Panel Number. FIRMettes can be generated electronically at no cost at the FEMA Map Service Center website. The FIRMette module is located in the upper left hand corner, while the tutorial is at the lower right hand corner of the webpage. (If Flood Insurance Rate Maps do not exist for the project site, a floodplain survey or consultation may be required.)

G.5. Will the proposed action include new construction or new site features (e.g., new buildings, additions, fences, parking lots, signage, etc.) in the floodplain?
[_] Yes [_] No

If yes explain:

G.6. Will the proposed action adversely impact flood flows in a floodplain or support development in a floodplain?
[_] Yes [_] No

If yes explain:

G.7. Will the proposed action include alter floodplain levels?
[_] Yes [_] No

If yes explain:

G.8. Will the proposed action discharge stormwater to the floodplain?
[_] Yes [_] No

If yes explain:

G.9. Is the project located in a state that borders the Atlantic Ocean, Pacific Ocean, Great Lake, Chesapeake Bay, or Gulf of Mexico?
[_] Yes [_] No [_] N/A

If yes, is your project located in the state's coastal zone?

[_] Yes [_] No [_] N/A

If yes, you may be asked in your NGA to contact your state coastal zone agency for a Section 307 Federal Coastal Zone Consistency Determination.

G.10. Will the action adversely affect a specifically designated Wildlife Refuge or Wilderness Area?
For assistance contact your State Fish and Wildlife Agency or the regional office of the U.S. Fish and Wildlife Service, .Bureau of Land Management, U.S. Forest Service, or National Park Service.
[_] Yes [_] No

If yes explain:

G.11. Will the action adversely affect a wild, scenic, or recreational river area or create conditions inconsistent with the character of the river? (A consideration for activities that are in or near any wild and scenic waterway including construction of stream/river crossings, intake structures, outfalls, etc.)
[_] Yes [_] No

If yes explain:

G.12. Will the action adversely impact an EPA designated sole source aquifer? (Designation of sole source aquifer puts restrictions and conditions on Federal expenditures, projects, and Awards.)
[_] Yes [_] No

If yes explain:

H. Pollutants

This set of questions is concerned with the presence of hazardous, toxic, or petroleum substances at levels which exceed Federal, state, or local regulations or standards requiring action or attention.

H.1. Will the action include renovation of an existing building or ground disturbing activities?
[_] Yes [_] No

If yes, has a Phase I Environmental Site Assessment been prepared for the property within the last 3 years?

H.2. Will the action take place on a site where past land uses may have led to contamination of soil, surface water, or groundwater?
[_] Yes [_] No

If yes explain:

I. Health and Safety

This set of questions is concerned with the potential for adverse impacts to human health and safety from the proposed action.

I.1. Will the action introduce major new sources of unshielded radiation?
[_] Yes [_] No

If yes explain:

I.2. Will the action require storage of waste pending technology for safe disposal?
[_] Yes [_] No

If yes explain:

I.3. Will the action adversely affect access to transportation, health, education, and/or welfare service?
[_] Yes [_] No

If yes explain:

I.4. Will the action result in changes in genetic engineering directed at the human population?
[_] Yes [_] No

If yes explain:

I.5. Will the action cause a new, large volume of production of non-recycled items?
[_] Yes [_] No

If yes explain:

I.6. Could the action disrupt existing health services' response in case of a disaster?
[_] Yes [_] No

If yes explain:

I.7. Will the action decrease accessibility to routine health services by altering point-of-service delivery?
[_] Yes [_] No

If yes explain:

I.8. Will the action increase by more than 5% the patient load of the area's routine care services?
[_] Yes [_] No

If yes explain:

J. Environmental Justice (Executive Order 12898)

This set of questions is concerned with consistency with Executive Order 12898, Environmental Justice in Minority Populations and Low-Income Populations

J.1. Are there low-income or minority populations in the vicinity of the proposed action?
[_] Yes [_] No

If yes explain:

J.2. Will the action have disproportionately high and adverse human health or environmental effects on minority populations and low-income populations?
[_] Yes [_] No

If yes explain:

J.3. Will the proposed action displace or relocate low-income or minority populations?
[_] Yes [_] No

If yes explain:

K. Other Federal, State, Local, or Tribal Laws

This set of questions is concerned with consistency with other federal, state, local or tribal laws or requirement imposed for the protection of the environment.

K.1. Will the action convert significant agricultural lands to non-agricultural uses or impact Prime Farmland Soils or Solis of Statewide Importance?
[_] Yes [_] No

If yes explain:

K.2. Will the action change traditional use of the land parcel (by rezoning, etc.)?
[_] Yes [_] No

If yes, has zoning change been requested and/or received? Explain
If yes, complete the following:
Present Zoning: ________________________
Present Use of Site: ________________________
Proposed Zoning: ________________________

K.3. Will the action have significant adverse direct or indirect effects on park land, other public lands, or areas of recognized scenic or recreational value? (For example, consider how the activity will affect the view?)
[_] Yes [_] No

If yes explain:

K.4. Will the action block access to known mineral deposits? (Sand, gravel, clay, stone, or other common building materials are not considered mineral deposits.)
[_] Yes [_] No

If yes explain:

L. Cumulative Impacts

Potential for significant cumulative impact when the proposed action is combined with other past, present and reasonably foreseeable future actions, even though the impacts of the proposed action may not be significant by themselves.

L.1. Has the area around the project undergone major changes in land use/development?
[_] Yes [_] No

If yes explain:

L.2. Are major changes in land use/development planned for the area around the project?
[_] Yes [_] No

If yes explain:

L.3. Will the action alter the use of other land by related development of stores, roads, or site changes?
[_] Yes [_] No

If yes explain:

M. Mitigative Measures

Please discuss any mitigative measures undertaken to minimize any environmental impacts. For example, utilizing the EPA's Energy Performance Environmental Assessment Tool (EPEAT) or EnergyStar guidance as part of IT selection and purchase criteria, using EPA's Environmentally Preferred Purchasing Guidance for 'green' products and services, or incorporating Sustainable Design or Leadership in Energy and Environmental Design (LEED) standards into alteration/renovation or new construction project.

Describe mitigative measures that will be incorporated into the action:

ENVIRONMENTAL INFORMATION AND DOCUMENTATION CERTIFICATION

[_] I certify that to the best of my knowledge and ability the information presented herein is true and correct (enter appropriate information in the shaded blanks):

Signature (Type Full Name):	Title or Position:	Phone Number:	Date:
(Award Recipient or responsible, knowledgeable person who completed this document)

Signature (Type Full Name):	Title or Position:	Phone Number:	Date:
(Award Recipient Authorized Representative)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0324. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, 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 this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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