Form 0324 HRSA NEPA EID

	OMB No. 0915-0324 Expiration Date:
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.
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration ENVIRONMENTAL INFORMATION AND DOCUMENTATION (EID)	FOR HRSA USE ONLY
	Grantee Name
	Grant Number		Application Tracking #
	Project #		Project Type
	Project Title

Grantee Authorized Official:
Phone:
Email:

Grantee EID Preparer:
Phone:
Email
Address:

A. USE OF NATURAL RESOURCES

This set of criteria is concerned with the use and accessibility of nonrenewable natural resources such as land, minerals, and fuels as well as the flow resources (water and air) which are constantly renewed but in which short-term or local shortages might occur.

1. Is there a controversy with respect to environmental effects of the action based on reasonable and substantial issues?
[_] Yes [_] No
If yes explain:

2. Will the action not comply with local and State land use planning?
[_] Yes [_] No
If yes explain:

3. Is the action significantly greater in scope than normal for the area, or will it have significant unusual characteristics?
[_] Yes [_] No
If yes explain:

4. Will the action change traditional use of the land parcel (by rezoning, etc.)?
[_] Yes [_] No
If yes, complete the following:
Present Zoning:____________________

Present Use of Site:_______________

Proposed Zoning:___________________

5. Will the action involve the purchase, construction or lease of new facilities (including portable facilities and trailers), or substantially increase the capacity of an existing health care facility?
[_] Yes [_] No
If yes explain:

6. Will the action alter the use of other land by related development of stores, roads or site changes?
[_] Yes [_] No
If yes explain:

a) Generate new stores?
[_] Yes [_] No
If yes explain:

b) Cause new roads?
[_] Yes [_] No
If yes explain:

c) Cause new parking?
[_] Yes [_] No
If yes explain:

7. Is the action located in either a 100-year or, for critical actions, a 500-year floodplain?
[_] Yes [_] No
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 http://www.msc.fema.gov. 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.)

8. Will the proposed action adversely impact flood flows in a floodplain or support development in a floodplain?
[_] Yes [_] No
If yes explain:

9. Will the action include the use of wetlands (swamps, marshes, etc.)?
[_] Yes [_] No
If yes explain:

10. Will the action decrease the volume of water in a lake, river table, reservoir, etc.?
[_] Yes [_] No
If yes explain:

11. Will the action change traditional use of a body of water?
[_] Yes [_] No
If yes explain:

12. Will the action violate 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 explain:

13. Will the action use land for purposes unsuitable to its physical characteristics? Consider these items: Soil borings have/have not been completed. Proposed facility will/will not have foundations similar to other facilities in the area. The facility is/is not in a flood plain.
[_] Yes [_] No
If yes explain:

14. Will the action adversely impact a Wilderness Area (Wilderness Areas are specifically designated areas of land)?
[_] Yes [_] No
If yes explain:

15. 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 your activity will affect the view?)
[_] Yes [_] No
If yes explain:

16. 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:

17. Will the action increase fuel and mineral consumption in State by more than 1% annually?
[_] Yes [_] No
Est. annual fuel requirements:
________ gallons of fuel
________ cubic feet of natural gas
________ tons of coal
________ kWh of electricity
Expected source(s) of these fuels:

B. POLLUTION

This set of criteria concerns the processes that generate pollution. These include the introduction of pollutants into the environment, changes in the flow of energy through the environment, and changes in the composition of environments through the augmentation or deletion of substances that are naturally present. The criteria are also directly concerned with the production and one-time use of materials and the proper disposal of wastes.

1. Will the action increase identifiable ambient air pollution levels from a new emission source or from existing sources?
[_] Yes [_] No
If yes explain:

2. Will the action increase identifiable ambient air pollution levels through a major increase in the number of or use of automobiles, trucks, etc.?
[_] Yes [_] No
Approximate number of new employees: ______

3. Will the action exceed city or State health standards with exhausts from fume hoods?
[_] Yes [_] No
If yes explain:

4. Will the action require major sedimentation and erosion control measures? (Consider earth disturbing activities including construction or expansion of a parking lot.)
[_] Yes [_] No
If yes explain:

5. Will the action involve:

a) Dredging or swamp drainage?
[_] Yes [_] No
If yes explain:

b) Construction of a waste treatment plant?
[_] Yes [_] No
If yes describe capacity and location:

c) Discharge of untreated human waste directly into a lake, river, etc.?
[_] Yes [_] No
If yes explain:

d) Discharge of laboratory wastes or biohazard wastes directly into a lake, river, etc.?
If Yes Describe:

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.

7. Will the action cause soil erosion (after completion of construction phase) or leaching of foreign substances (such as salt) into soil?
[_] Yes [_] No
If yes explain:

8. Will the action allow seepage of contaminants into the water table?
[_] Yes [_] No
If yes explain:

9. Will the action place stress upon an identified earthquake fault?
[_] Yes [_] No
If yes, please include a statement from a structural engineer.

10. Will the action create an identifiable change in aquatic life by discharge of hot water?
[_] Yes [_] No
If yes explain:

11. Will the action impact an EPA designated sole source aquifer? (Designation of sole source aquifer puts restrictions and conditions on Federal expenditures, projects, and grants.)
[_] Yes [_] No
If yes explain:

12. Will the action decrease the percolation on more than one acre of land?
[_] Yes [_] No
If yes explain:

13. Will the action violate a storm water permit or a wastewater discharge permit either for construction or on-going operations? (Earth disturbing activities may require a Notice of Intent (NOI) to be covered under a storm water general permit or individual permit from the EPA or other agency and a storm water control plan, including some parking lot construction activities. A discharge of wastewater to the environment may require a permit from Tribal, local or State authorities, or EPA.)
[_] Yes [_] No
If yes explain:

14. Will the action involve the sale or transfer of real property, on which any hazardous substance was stored for one year or more, known to have been released, or disposed of? (Provide relevant documentation for any hazardous substance releases. See 40 CFR 373.2(b), 302.4, and 261.30 for reportable quantities.)
[_] Yes [_] No
If yes explain:

Consider the following statements prior to answering questions 17-19: Facility will/will not emit noises in excess of local noise standards. Is facility near a wildlife sanctuary? Are outdoor animal facilities included? Facility will/will not contain x-ray machines. Facility will/will not meet Atomic Energy Commission standards.

15. Will the action produce noises considered offensive to a human population?
[_] Yes [_] No
If yes explain:

16. Will the action create sounds that result in changes in behavior patterns of animals?
[_] Yes [_] No
If yes explain:

17. Will the action introduce major new sources of unshielded radiation?
[_] Yes [_] No
If yes explain:

18. Will the action cause shock waves and/or vibration (after construction phase)?
[_] Yes [_] No
If yes explain:

19. Will the action change the direction and wind velocity as to affect the local population (i.e., high-rise building)?
[_] Yes [_] No
If yes explain:

20. Will the action cause a new, large volume of production of non-recycled items?
[_] Yes [_] No
If yes explain:

21. Will the action result in the non-recycling of recyclable items such as laboratory glassware, animal cages, and office paper?
[_] Yes [_] No
If yes explain:

If no, indicate number of:
Glassware-washing machines: _____
Cage-washing machines: _____

22. Will the action generate solid wastes that cannot be properly disposed of by existing facilities?
[_] Yes [_] No
If yes, describe proposed methods and disposal sites.

23. Will the action dispose of solid wastes in polluting landfills, wells, caves, etc.?
[_] Yes [_] No
If yes explain:

24. Will the action require storage of waste pending technology for safe disposal?
[_] Yes [_] No
If yes explain:

25. Will the action not comply with Federal, State, and local requirements for waste handling, transportation, or disposal methods?
[_] Yes [_] No
If yes, describe proposed methods:

C. POPULATIONS

This section of the initial criteria addresses changes in human and plant populations. NOTE: For these criteria, the affected area is defined as being greater than 160 acres in size.

1. Will the action result in a 5% change in the density of the local population?
[_] Yes [_] No
If yes:
Est. local population: ____________
Number of new employees: _______

2. Will the action result in an alteration of transportation, health, education, and/or welfare service?
[_] Yes [_] No
If yes explain:

3. Will the action result in a change in social service needs by altering population�s age pattern (new schools, etc.)?
[_] Yes [_] No
If yes explain:

4. Will the action result in a 5% change in the transient population?
[_] Yes [_] No
If yes, include estimated number of:
Visitors: _______________
Patients: _______________
Students: ______________

5. Will the action result in changes in genetic engineering directed at the human population?
[_] Yes [_] No
If yes explain:

6. Will the action result in a violation of local, State, or Federal standards pertaining to population densities or conservation of plants and animals?
[_] Yes [_] No
If yes explain. Also describe any approvals needed or submit those already obtained:

D. HUMAN SERVICES

As society has evolved, traditional self-sufficient human communities have given way to dense populations that depend upon the development and application of technology. Man�s highly complex, technological environments are maintained by a variety of services, ranging from the provision of the basic necessities of food and water to complex systems of economic exchange. These services are largely interdependent, and their complexities must be considered. NOTE: In this section, the human environment impacted upon is defined as less than 160 acres in size.

1. Could the action disrupt food supplies for over 48 hours?
[_] Yes [_] No
If yes explain:

2. Could the action disrupt water supplies for over 48 hours?
[_] Yes [_] No
If yes explain:

3. Could the action disrupt electrical power for over 48 hours?
[_] Yes [_] No
If yes explain:

4. Could the action disrupt heating supplies (natural gas, heating oil) for over 48 hours?
[_] Yes [_] No
If yes explain:

5. Could the action deprive population of housing for over 48 hours?
[_] Yes [_] No
If yes explain:

6. Could the action disrupt removal of sewage for over 12 hours?
[_] Yes [_] No
If yes explain:

7. Could the action disrupt removal of solid waste (trash) for over 7 days?
[_] Yes [_] No
If yes explain:

8. Could the action disrupt existing health services� response in case of a disaster?
[_] Yes [_] No
If yes explain:

9. Could the action disrupt telephone, telegraph, radio, or mail service for over 2 weeks?
[_] Yes [_] No
If yes explain:

10. Could the action disrupt transit service for over 2 weeks?
[_] Yes [_] No
If yes explain:

11. Will the action use more than 5% of remaining electrical capacity? (Will the project require electrical upgrades?)
[_] Yes [_] No
If yes:
Estimated daily usage is ____ kWh.
Please obtain and submit an approval letter from local utility or plant engineer.

12. Will the action use more than 5% of remaining water?
[_] Yes [_] No
If yes:
Estimated daily usage is ____ gallons.
Please obtain and submit an approval letter from local utility or plant engineer.

13. Will the action use more than 5% of available capacity of the sewage treatment system (branch lines, mains, plants)?
[_] Yes [_]
No Estimated daily flow is ____ gallons.
Please obtain and submit an approval letter from local utility.

14. Will the action use more than 5% of available capacity of trash disposal system (collection, incinerator plant, and landfill)? Also clearly explain proposed handling and disposal of chemical wastes, biohazards, syringes, and other special wastes.
[_] Yes [_] No
If yes explain:

15. Will the action use more than 5% of available heating fuel (gas, coal or heating oil)?
[_] Yes [_] No
Annual quantities have already been described. Explain which of these fuels, if any, are in short supply.

16. Will the action decrease by 5% the food delivery system by removal of retail food stores etc.?
[_] Yes [_] No
If yes explain:

17. Will the action decrease by 5% the area�s domestic housing by demolition, closing, etc.?
[_] Yes [_] No
If yes explain: Will any housing be demolished, closed, etc.?

18. Will the action decrease by more than 5% the use of existing transit systems (bus, train, etc.)?
[_] Yes [_] No
If yes explain: Relate to extent of new employment.

19. Will the action decrease accessibility to routine health services by altering point-of-service delivery?
[_] Yes [_] No
If yes explain:

20. Will the action increase by more than 5% the patient load of the area�s routine care services?
[_] Yes [_] No
If yes explain:

21. Will the action change the availability of social services by opening or closing facilities?
[_] Yes [_] No
If yes explain:

22. Will the action increase by more than 5% the number of social services recipients (through unemployment)?
[_] Yes [_] No
If yes explain:

23. Will the action cause discontinuation of existing stops or train stations?
[_] Yes [_] No
If yes explain:

24. Will the action increase by more than 5% the annual volume of telephone, telegraph, or mail?
[_] Yes [_] No
If yes explain:

25. Will the action eliminate employment sources for 10% of the population?
[_] Yes [_] No
If yes explain:

26. Will the action change school enrollment by more than 5%?
[_] Yes [_] No
If yes explain:

E. HUMAN VALUES

The fifth set of criteria is directed toward human values concerning the environmental qualities generally agreed upon to the extent that they are stated in statutes, standards, or regulations.

1. Will the action involve the purchase, construction, alteration, renovation, or lease of real property or portion of real property that is more that 50 years old? Will the action encroach upon any historical, architectural, or archeological cultural property? Will the proposed action adversely affect properties listed, or eligible for listing, on the National Register of Historic Places? [Buildings, archaeological sites, National Historic Landmarks; objects of significance to a Tribe including graves, funerary objects, and traditional cultural properties.]
[_] Yes [_] No
If yes explain: Obtain and submit clearance letters from State Historic Preservation Officer. For assistance, consult with the State Historic Preservation Officer (SHPO) or the Tribal Historic Preservation Officer (THPO)]

2. 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? (Discovering an endangered or threatened species in the project area will stop the project, and the Endangered Species Act has significant fines and penalties for violations.)
[_] Yes [_] No
If yes explain: For assistance, consult with the State Historic Preservation Officer (SHPO) or the Tribal Historic Preservation Officer (THPO)

3. Will the action convert significant agricultural lands to non-agricultural uses and exceed 160-point score on the farmland impact rating?
[_] Yes [_] No
If yes explain:

4. Will the action directly affect a Coastal Zone in a manner inconsistent with the State Coastal Zone Management Plan? (All Federal programs or projects in the coastal zone must comply with the consistency provisions of the Act. Each coastal State should have a State office to manage its coastal zone development and use. )
[_] Yes [_] No
If yes explain:

5. 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:

F. Mitigative Measures

Please discuss any mitigative measures undertaken to minimize any environmental impacts. For example, utilizing EPEAT or EnergyStar guidance as part of IT selection and purchase criteria, or incorporating Sustainable Design or Leadership in Energy and Environmental Design (LEED) standards into alteration/repair/renovation or new construction project.

Discuss Mitigative Measures:

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 #	Date
(Grantee or responsible, knowledgeable person who completed this document)

Signature (Type Full Name)	Title or Position	Phone #	Date
(Grantee Authorized Representative)