Attachment D - 13.4 App B SSER Ph II Template.pdf

TECHNICAL HANDBOOK FOR ENVIRONMENTAL HEALTH AND ENGINEERING VOLUME II HEALTH

CARE FACILITIES PLANNING

PART 13 ‐ SITE SELECTION AND EVALUATION PROCESS

January 2024 (13‐4) 63 TN‐X

Phase II (Selected Site Evaluation SSER) Prototype/Template Report

PHASE II

SITE SELECTION AND EVALUATION REPORT INDIAN HEALTH SERVICE

[Name and Type of Facility]

[Location], [State]

[Month] [Year]

Instructions:

1. Edit document as appropriate to fit the needs of the proposed project

2. Fill in the blank. Wherever there is a “[text]” replace with the requested information (e.g.”[Month] [Year] to “June

2019”)

3. Multiple Choice. Wherever there is a “[text OR text]” select the applicable sentence or choice and delete those remaining. Edit as needed (e.g. “Road Access to the chosen site [does not require any improvements or new traffic control devices. OR requires the following improvements….]” to “Road Access to the chosen site does not require any improvements or new traffic control devices.”)

4. Essay. Wherever there is a request for information, such as; “[Include a description of …]” provide a narrative of the requested information along with any other information that may be important or relevant.

5. Make Sure the completed document does not contain leftover random “[“ s,“]”s and/or “OR”s

6. Use only one system of units, metric or imperial, not both. Generally, a project should use the same system of units from start to finish. The unit system used in the PJD/POR should be the same as that used in the SSER.

7. Delete all GREEN instruction text from completed document

[Division of Engineering Services OR Area IHS preparing document]

Office of Environmental Health and Engineering

Indian Health Service

Department of Health and Human Services

January 2024 (13‐4) 64 TN‐X

SITE SELECTION AND

EVALUATION REPORT

INDIAN HEALTH SERVICE

[Name and Type of Facility]

[Location], [State]

PREPARED BY:

P.E. .

[Name] Date [Title] Office of Environmental Health and Engineering [or appropriate TOP/Tribe] [Area Name] Area Indian Health Service

RECOMMEND APPROVAL:

[Name] Director Date Division of Health Facilities [Area Name] Area Indian Health Service

APPROVE:

[Name] Date Associate Director Office of Environmental Health and Engineering [Area Name] Area Indian Health Service

January 2024 (13‐4) 65 TN‐X

SITE SELECTION AND

EVALUATION REPORT

INDIAN HEALTH SERVICE

[Name and Type of Facility]

[Location], [State]

Table of Contents

I. EXECUTIVE SUMMARY

II. BASIC PROJECT DATA

III. LAND AREA REQUIREMENTS

IV. PROPERTY LOCATION

V. ACCESS

VI. OWNERSHIP INFORMATION

VII. PHYSICAL DESCRIPTION

VIII. WATER SUPPLY AND WASTEWATER DISPOSAL

IX. STORMWATER MANAGEMENT

X. MEDICAL AND SOLID WASTE DISPOSAL

XI. RENEWABLE ENERGY CONSIDERATIONS

XII. ENERGY AND POWER

XIII. INFORMATION TECHNOLOGY (IT) AND DATA SYSTEMS INFRASTRUCTURE REQUIREMENTS

XIV. EMERGENCY RESPONSE

XV. ENVIRONMENTAL REVIEW AND DETERMINATION

XVI. SERVICE AVAILABILITY

XVII. SUSTAINABILITY

XVIII. SECURITY CONSIDERATIONS

XIX. TECHNICAL EVALUATION (E.G. GEOTECHNICAL INVESTIGATIONS, TRAFFIC STUDY, ETC.)

XX. CONCLUSIONS AND RECOMMENDATIONS

XXI. APPENDIX/TABS

TAB A MAPS

SERVICE UNIT

LOCAL AREA

SITE PLAN(s)

PROPOSED SITE ACCESS PLAN

ZONING

TOPOGRAPHY

SANITATION

SOILS

FLOODPLAIN

WETLAND

FEMA

DRAINAGE

EASEMENTS

TAB B TRIBAL RESOLUTIONS

TAB C BIA VERIFICATION OF PROPOSED SITE AVAILABILITY

TAB D FLOOD PLAIN CLEARANCE

TAB E GEOTECHNICAL REPORTS

TAB F ARCHAEOLOGICAL REPORT

TAB G CORRESPONDENCE (Utilities)

TAB H ENVIRONMENTAL ASSESSMENT

January 2024 (13‐4) 66 TN‐X

I. EXECUTIVE SUMMARY

Project Description:

This Phase II Site Selection Evaluation Report (SSER) was produced for [Project Name] located at [Community Name, Reservation, State]. This report verifies that the chosen site is suitable for the proposed project and presents data for use in the design phase. [This report validates the technical data and concurs with the site selection presented in the Phase I SSER. OR This report concurs with the site selection presented in the Phase I SSER and updated the technical data. OR There was not a Phase I SSER because the project scope is at an existing facility and site.] The selected site is [Number] [Acres OR ha]. An overview the project is presented in the table below.

Project Overview

Project Name/Number Project Name and Number IHS Area Office Area Office Name Service Unit Service Unit Name Reservation Reservation Name Facility Name and Location Facility Name and Community Name Tribe(s) Served Name of tribe(s)] Service Delivery Compacted OR Contracted OR Direct Service] Owner Name [IHS OR [Tribe Name] OR [Tribal Organization Operator [IHS OR [Tribe Name] OR [Tribal Organization Name]] Health Care Facility Type Hospital OR Alternative Rural Health Care OR Standalone Ambulatory Surgery OR

Health Center OR Health Station OR Alaska Village Clinic OR Health Location OR Long Term Care OR Alcohol Substance Abuse Treatment OR Small Ambulatory OR Outpatient Behavioral Health (BH) OR Inpatient BH OR Dental Clinic OR Quarters]

Funding Type [IHS Health Care Facilities Construction Appropriations OR Joint Venture OR Maintenance and Improvement (M&I) OR Medicaid Medicare 3rd Party Collections M&M) OR list other]

Project Type New Building OR Addition OR Renovation OR [Describe Combination Estimated Project Cost [$ Value] Chosen Site Size [Number] [Acres OR ha]

[Include a brief description of any major special components or other pertinent/special project information.]

Acknowledgments:

[Acknowledgments that identify the authors, names and organization of individuals involved in the preparation of the report, or team members if a review team is reconstituted for this phase.]

Findings and Recommendations:

[Briefly state the results of the Phase II SSER Report, including a summary of the land and utilities specifications, selected site data, Environmental Determination, unresolved issues, areas of concern, final conclusion and recommendations. Summarize any unusual or additional costs that must be added to the budget estimate. Repeat any important information from the recommendations and conclusions section of this report.]

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The proposed use of the site [corresponds ideally OR corresponds OR has some variance] with tribal, local and regional planning Goals.

II. BASIC PROJECT DATA

Should match the data in the POR or include an explanation for differences

Detailed data on the [Project Name] project can be found in the Program Justification Document (PJD), the Program of Requirements (POR) document, and their amendments. A summary of building space improvements planned under this project are shown below.

Project Gross Building Space [(m2 OR ft2)] and Staff Quarters (Number of Units) Estimates

Facility/Building/Department Existing To Be

Renovated To Be Used

“As Is” To Be

Demolished

To Be Constructe d

Total Space Upon

Completion [List those impacted] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] Staff quarters (Number of Units) [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number] [Number]

The Basic Project Data is shown in the table below.

Basic Project Data Facility Name and Location [Facility Name and Location] Health Care Facility Type [Hospital OR Alternative Rural Health Care OR Standalone Ambulatory Surgery OR

Health Center OR Health Station OR Alaska Village Clinic OR Health Location OR Long Term Care OR Alcohol Substance Abuse Treatment OR Small Ambulatory OR Outpatient Behavioral Health (BH) OR Inpatient BH OR Dental Clinic OR Quarters]

Funding Type [IHS Health Care Facilities Construction Appropriations OR Joint Venture OR Maintenance and Improvement (M&I) OR Medicaid Medicare 3rd Party Collections M&M) OR list other]

Project Type [New Building OR Addition OR Renovation OR [Describe Combination]] Existing Facility Size [Number] [m2 OR ft2] Proposed Facility Size [Number] [m2 OR ft2] Proposed New Space [Number] [m2 OR ft2] Space to be Renovated [Number] [m2 OR ft2] Proposed New Quarters [Number] Existing Quarters [Number] Quarters to be Renovated [Number] Estimated Project Cost [$ Value] Program Type [Direct Service, 638, Joint Venture, M&I, M&M, Replacement, etc.] Project Type [New, Addition, Renovation, Combination] Proposed Health Care Facility Size [Gross Square Meters (m2) or ft2] Health Care Facility Chosen Site Size Number] [Acres OR ha] and [% Number] percent the size of the recommended site size.

Facility Fee or Trust Property [Fee OR Trust] Property

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Basic Project Data

# Of Quarters Units [Number] Chosen Quarters Unit’s Site Size Number] [Acres OR ha] and [% Number] percent the size of the recommended site size.

Quarters Fee or Trust Property [Fee OR Trust] Property Current [year] User Population [Number] Design [year] User Population [Number] Annual Patient Provider Visits (PCPV) [Number] Number of Inpatient Beds [Number] Annual Outpatient Visits (OPV) [Number] Annual Dental Minutes [Number] Number of Staff [Number] Govt Vehicles [Number] Bus Parking Capacity [Number] Staff Quarters [Number of Units] Special Components [List] Occupancy Type [Healthcare Occupancy, Ambulatory Healthcare Occupancy, or Other]

III. LAND AREA REQUIREMENTS

The required site area for the facility was estimated [[describe how the required area was estimated] OR to be about nine times the facility footprint and takes into consideration:

• Security requirements of a [(15 m) OR (50 ft)] envelope around the building;

• A vegetated open space equal to the building footprint per LEED to promote biodiversity;

• About 10% of the footprint and parking area (main impervious surfaces) for onsite stormwater retention;

• Five parking spaces per [(100 m2) OR (1,0750 ft2)] of footprint space (parking space includes half an aisle);

• On-site wastewater disposal;

• A 25% footprint expansion area;

• A small allotment for fuel storage, water storage and misc.; and

• A 1.2 safety factor.

The land area requirement for staff quarters was estimated [[describe how the required area was estimated] OR by multiplying the number of required quarters by 0.14 ha or 0.35 acres.

This assumes 5% of the proposed space for staff quarters is for recreational facilities.]]

For Quarters, space deviating by ±1% from the IHS conventional 5% for recreation or other special features must be justified.

The Land Area Required for the total proposed facility and each component of the facility is listed in the table below along with the available area of the chosen site.

January 2024 (13‐4) 69 TN‐X

Selected Site Land Area and Estimated Land Area Requirement (Acre or Ha)

Component Estimated Size Requirement Chosen Site Size

Proposed Health Care Facility Site

Other Authorized Special Facilities For Health Care Facility [List]

Proposed Staff Quarter’s Site

Other Authorized Special Facilities For Staff Quarters [List]

Total Land Area

IV. PROPERTY LOCATION

The property location(s) of the chosen site(s) are shown below.

Selected Site Location(s)

Health Care Facility Site Quarters Site

Community Name

GPS Coordinates

Street Address

See map in appendix Tab A The chosen health care facility site is [within OR within walking distance [(≤ ¼ mile OR 400 meters)] of OR within a 15 minute vehicle/bus ride of] the [central business district OR rural town center OR community center] of [Name]. The chosen site is [[adjacent to OR within walking distance of [Name of federal, state, or local government entity(s) and local school(s)]] OR not in proximity to federal, state, or local government entities or schools]. The chosen site is [adjacent to OR within walking distance of OR within a 15 minute vehicle/bus ride of the existing Staff Quarters. The Chosen site is [adjacent to OR within walking distance of OR within a 15 minute vehicle/bus ride] of the proposed Staff Quarters. The chosen facility site [is OR is not] on a public transportation route. The chosen site [is OR is not] on established pedestrian and bicycle routes.

The chosen health care facility construction site is [an addition to OR is adjacent to OR is within a single campus OR within walking distance of] the [IHS OR Tribal] complementary health care services that will continue to be provided in a facility that is not part of this project.

The chosen proposed staff quarter’s site is [adjacent to OR within walking distance of OR within a 15 minute vehicle/bus ride of the [existing OR proposed]] health care facility. The chosen quarter’s site is [adjacent to OR within walking distance of OR within a 15 minute vehicle/bus ride of] the existing staff quarters that will remain in use. The chosen quarter’s site [is OR is not] on a public transportation route. The chosen quarter’s site [is OR is not] on established

January 2024 (13‐4) 70 TN‐X pedestrian and bicycle routes.

V. ACCESS

If there are more than one chosen site, (e.g. separate site for staff quarters) include Access narrative for each site.

Road Access Entrance to selected project site will be off [Name], a [National Highway OR major arterial roadway OR minor arterial roadway OR low volume internal residential-only road OR collector road OR a frontage road.] [Name] is the responsible party for maintenance and repair of the access road. The access roads are [within standards for width, grade, and drainage OR [specify issue]]. Road access to the chosen site [does not require any improvements or new traffic control devices. OR requires the following improvements: [Describe Needed Improvements….] Adequate Entranceways Sight Distance [already exists OR is easy without major work OR will require clearing and earthwork OR [Describe]]. [Identify source of funding and amount estimated for any major improvements to access road(s)] [Describe any records of easement].

Transporting construction materials and equipment to the site will be [very difficult OR only feasible seasonally OR easy with minor [describe infrastructure need (e.g. road, etc.)] upgrades.] OR simple with existing routes OR [describe mobilization issues].

The site will allow [only one entrance and has limited internal circulation options OR only one entrance, but has options for internal circulation OR more than one entrance, but limited internal circulation potential OR more than one entrance and internal circulation options OR [describe]].

Pedestrian Routes are [not available, nor is construction feasible OR constructible with significant work OR constructible at-grade without major work OR existing for at least [¼ mile OR 400 meters], but needs new traffic control devices OR existing for at least [¼ mile OR 400 meters], and doesn’t require new traffic control devices].

VI. OWNERSHIP INFORMATION

The selected site is [trust status OR fee status] property currently owned by [Name]. [Describe any known title/deed conditions and/or ownership issues.] [This trust site can be set-aside by the tribe and is availability for construction for the health care facility and/or quarters]. The site is [above fair market value but within reach OR available at fair market value OR available below fair market value OR Site is available at no cost or a nominal fee].

VII. PHYSICAL DESCRIPTION

Briefly describe the current/pre-project site locations of streams, swales, ridges, significant landforms, wetlands, floodplains, large trees, tree cover, culverts, paved areas, fences power lines, gas, lines, easements, encroachments for adjacent structures, on-site roads, presence of land locked parcels, cemeteries (adjacent or on-site), historical properties or any other unique feature. Be sure to include any evidence of trespass, foot trails, sports fields or any other suggest prior use that could be cause for community opposition should be noted. Referenced maps can be included here or in an appendix. Phase II SSER will include a geotechnical report, edit/update the geotechnical information below to match report. The Stormwater section should address how drainage issues will be addressed.

January 2024 (13‐4) 71 TN‐X

The site [has significant topographic relief OR is not level and will need significant cut and fill OR is not level and will need some cut and fill OR site is mostly level and needs minor cut and fill OR is level]. The site [is low and surrounding areas drain into it OR collects runoff/drainage in some areas within the site OR has runoff/drainage that collects in areas adjacent to the site OR has no significant drainage issues]. The site has [a known erosion risk/potential OR a moderate risk/potential of erosion, mostly during construction OR little erosion risk potential]. The site configuration might compromise security buffers and interfere with the layout OR allows security buffers and options for layout OR support optimum building layout and orientation]. [The site has [Names Feature (e.g. large trees, stands of trees)] that will enhance site development.] The selected site [has no risk of air inversions, Katabatic Winds and/or cold air accumulation OR has continuous winter Katabatic accumulations OR is routinely affected by Katabatic accumulation OR experiences Katabatic wind, but not every season OR is adjacent to areas of Katabatic accumulation OR is on a hillside above cold air accumulation areas].

Geotechnical investigation results should be summarized. Any geotechnical information and recommendations that may impact design should be stated here (i.e. topographic features, soils, foundation considerations, seismic considerations, drainage, slopes, slope stability, rock, rock outcrops, and erosion).

A geotechnical investigation [was not conducted OR was conducted and the report dated [Date] is included in the appendix of this report]. The site has [unstable soils and a specialized foundation will be required OR mostly unstable soils and a specialized foundation will be required OR isolated unstable soils and a specialized foundation is likely OR mostly stable soils and a conventional foundation is possible OR stable soils and a conventional foundation is possible]. [Significant bedrock was seen on site OR Rock outcroppings were seen on site OR There was no visible sign of rock seen on site OR The Absence of rock was confirmed by the geotechnical report]. The site soils are [saturated OR poorly drained OR well drained]. The site soils have a [high organic matter content OR high silt and clay content OR low organic matter and clay content].

VIII. WATER SUPPLY AND WASTEWATER DISPOSAL

The selected site will allow the adequate provision of potable water and wastewater disposal.

Use only one of the following paragraphs; the 1st one is used when public water systems are available and the 2nd is used when a public water system is not available.

There is a public water system [available to the site OR available with a short extension and minor upgrades OR possible with a major system extension and upgrades]. The public water system is owned and operated by [Name of utility]. The public water system [consistently meets OR regularly does not meet] water quality standards. The system has capacity to serve the project site. [Describe: the location, depths and sizes of existing distribution lines; connection fees; and utility fees (if known/available)].

There is not a public water system available to the chosen site, however, there is on site [an existing water system OR an existing water source OR a potential onsite source]. The existing onsite system is [in good repair OR in disrepair]. The existing [system OR source] [can OR does OR does not] water quality standards. [Describe: any existing onsite facilities that are to be utilized; depth to water table; potable water source type; potable water treatment; raw water quality; available water quantity; nearby sources of contamination; space required for potable

January 2024 (13‐4) 72 TN‐X water facilities; and an estimate of proposed water infrastructure needs, costs, and funding source].

Potable water need is calculated based on the number of Outpatient Visits (OPV), Average Daily Patient Load (ADPL), number of staff and the number of staff quarters. The IHS estimates potable water demand at [115 liters per day (lpd) per staff, plus 115 lpd per OPV, plus 570 lpd per ADPL, plus 1,300 lpd per staff quarters.

OR 30 gallons per day (gpd) per staff, plus 30 gpd per OPV, plus 150 gpd per ADPL, plus 340 gpd per staff quarters.]

An onsite water storage tank [will not be needed OR of about [Number] [gallon OR liter] will be needed] for potable water and fire flow capacity.

Characteristics of Selected Site and Estimated Site Requirement

Component Estimated Requirement Available at Chosen Site Potable Water Supply [gpd OR lpd] Potable Water Pressure [psi OR kPa] Wastewater Disposal Capacity [gpd OR lpd] Fire Flow [gpm OR lpm]

If there are more than one chosen site, (e.g. separate site for staff quarters) include specific sanitation information for each site. If there is a 2nd system onsite include available information

Wastewater generation is estimated to be 80% of the potable water usage.

Use only one of the following paragraphs; the 1st one is used when public systems are available and the 2nd is used when a public system is not available.

***Information about public systems, available capacity, operating utilities and fees needs to be included. The location, depths and sizes of existing collection and distribution lines should be noted along with lift station needs.

Onsite wastewater disposal issues ranging from required space, treatment methods, soil suitability and depth to water table must be identified.***

There is a public sewer system [available to the site OR available with a short extension and minor upgrades OR possible with a major system extension and upgrades]. The connection to the collection system [will require a sewage lift station OR will operate by gravity]. [Describe: the location, depths and sizes of existing collection lines; connection fees; and utility fees (if known/available)]. [Describe proposed wastewater infrastructure needs, with a cost estimate and funding source].

***OR***

There is not a public sewer system available for the site, however, [there is an existing adequate onsite system with sufficient capacity to serve the project needs OR the site has sufficient space and suitable soils for an onsite wastewater treatment system.] [Describe: the location, depths and sizes of existing collection lines; onsite wastewater disposal space requirements; proposed wastewater treatment, soil suitability; and depth to water table]. [Describe proposed wastewater infrastructure needs, with a cost estimate and funding source].

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Available/known details on any existing on-site wastewater collection and disposal facilities including asset format description of infrastructure, available capacity; locations, depths and conditions can be summarized here and/or included in the appendix.

IX. STORMWATER MANAGEMENT

The level of effort required and strategy for managing stormwater will vary regionally and by project scope.

[Summarize the onsite drainage patterns and any offsite drainage issues described in the previous Physical Description Section highlighting any issues of concern.] The selected site has adequate space for stormwater collection and disposal facilities. The construction of onsite stormwater retention/detention/infiltration facilities for this project [will not be required OR will be required and is estimated to occupy [Number] [ft2 OR m2] of site space]. [Describe the onsite drainage improvement needs and if applicable the Snow Disposal Space needs]. [The facility footprint in this project does not exceed [5,000 ft2 OR 455 m2] OR the selected site will allow the predevelopment hydrology with regard to the temperature, rate, volume, and duration of flow to be maintained and/or restored in compliance with section 488 of the Energy Independence and Security Act of 2007 by utilizing planning, design, construction, and maintenance strategies].

X. MEDICAL AND SOLID WASTE DISPOSAL

Discuss the operations for disposal of medical waste and solid waste. Provide name(s) of companies which provide this service and include approximate costs.

There is a legal, approved medical and solid waste system operated by [Name(s)] for the collection, source separation, storage, transportation, transfer, processing, treatment, incineration and disposal of waste.

XI. RENEWABLE ENERGY CONSIDERATIONS

Infrastructure needs for geothermal, solar, and/or wind power generation should be listed. Any studies evaluating the production of renewable energy on this site should be references with the report included in the appendix of this SSER.

The selected site is [in constant shadow fall through spring OR mostly shaded in winter with some fall and spring sun OR mostly exposed to winter sun OR is in year-round sun exposure with some obstructions OR full year-round sunlight with no obstructions.] The site is [fully exposed to OR mostly exposed to OR mostly protected by some natural barriers from OR offers full protection from] the prevailing winds. Solar Power [is not feasible at this site OR is feasible, but outside of the project scope OR will be utilized to provide [at least 30 percent of the energy need OR will be utilized to provide up to 30 percent of the energy need]]. The site [has OR does not have] potential for passive solar heating. The site [has OR does not] have trees that can remain for shade. The chosen site has [an existing functional geothermal system OR known geothermal resources OR potential geothermal resources OR no known geothermal resources].

The planned use of renewable energy collected onsite from [wind OR solar OR a geothermal system] [is OR is not] included in the site’s available energy and power evaluation. Use of this

January 2024 (13‐4) 74 TN‐X site [will OR will not] contribute to the IHS goals mandated in the Energy Policy Act of 2005 (requires a >30% reduction in energy use per unit area in federal buildings) and the Energy Independence and Security Act (requires >7.5% of the total electricity consumed in IHS facilities come from renewable energy).

XII. ENERGY AND POWER

The selected site has an adequate supply of energy that can be furnished at a sufficient rate to meet the estimated demand of the proposed facility.

Edit table as needed. Typically the site will use either natural gas, propane or heating oil and not all three; delete the rows that are not applicable.

Energy and Power of Selected Site versus Estimated Site Requirement

Component Estimated Requirement Available at Chosen Site Electrical Energy (kWh/year) Electrical Power (kVA) Natural Gas Energy ([m3/year OR ft3/year]) Natural Gas Power ([m3/hr OR ft3/hr]) Propane Energy ([liters/year OR gallons/year ]) Heating Oil Energy ([liters/year OR gallons/year ])

The proposed facility’s energy source mix was assumed to be [Number] percent electrical and [Number] percent from [Source type i.e. natural gas or propane etc.]. The estimated values for the annual electrical energy need and Apparent Power12 include a 1.25 multiplier to accommodate the code (NEC or other) and provide a factor of safety. The suggested energy budget was based on data from the Energy Information Administration, (EIA) 2012 Commercial Building Energy Consumption Survey (CBECS), and the 2009 Building Energy Data Book for Newly Constructed Hospitals and Medical Facilities. The power demand value is based on the International Electrotechnical Commission (IET) Building Area Method, EIA 2012 CBECS and the National Electrical Code (NEC) minimum loads. The values also accounted for regional or climatic conditions.

The formulas used for the minimum Electrical Energy and Power available are:

January 2024 (13‐4) 75 TN‐X

Electrical Need by Building Gross Area (BGA)

Inpatient

Energy kWh/yr = 1.25 X [% electrical source] X Building Gross Area (BGA) [m2 X 440 kWh/m2/yr OR ft2 X 41 kWh/ft2/yr]

Power kVA = 1.25 X BGA [m2 X 0.15 kVA/m2 OR ft2 X 0.014kVA/ft2]

Outpatient

Energy kWh/yr = 1.25 X [% electrical source] X Building Gross Area (BGA) [m2 X 210 kWh/m2/yr OR ft2 X 20 kWh/ft2/yr]

Power kVA = 1.25 X BGA [m2 X 0.14 kVA/m2 OR ft2 X 0.013kVA/ft2]

Staff Quarters

Energy kWh/yr = 1.25 X [% electrical source] X Building Gross Area (BGA) [m2 X 125 kWh/m2/yr OR ft2 X 12 kWh/ft2/yr]

Power kVA = 1.25 X BGA [m2 X 0.14 kVA/m2 OR ft2 X 0.013kVA/ft2]

The formulas for the minimum Fuel available are expressed in the equations below. For basis of calculating total fuel need for this facility, it is assumed the source is 100% natural gas:

Fuel Need - Natural Gas

Inpatient

Energy [m3/yr =% natural gas source X BGA m2 X 41.5 m3/m2/yr OR ft3/yr =% natural gas X BGA ft2 X 137 ft3/ft2/yr]

Power [m3/hr = BGA m2 X 0.02 m3/m2/hr OR ft3/hr =BGA ft2 X 0.065 ft3/ft2/hr]

Outpatient

Energy [m3/year = % natural gas source BGA m2 X 20 m3/m2/yr OR ft3/yr = % natural gas source X BGA ft2 X 65 ft3/ft2/yr

Power [m3/hr = BGA m2 X 0.015 m3/m2/hr OR ft3/hr = BGA ft2 X 0.035 ft3/ft2/hr]

Quarters

Energy [m3/year = % natural gas source BGA m2 X 12 m3/m2/yr OR ft3/yr = % natural gas source BGA ft2 X 65 ft3/ft2/yr]

Power [m3/hr = BGA m2 X 0.015 m3/m2/hr OR ft3/hr = BGA ft2X 0.03 ft3/ft2/hr]

OR

Fuel Need – Liquid Propane

Inpatient

Energy [liters/yr = BGA m2 X 64 liters/m2/yr X % propane source OR gallons/yr = BGA ft2 X 1.6 gallons/ft2/yr X % propane source]

Outpatient

Energy [liters/yr = BGA m2 X 32 liters/m2/yr X % propane source OR gallons/yr = BGA ft2 X 0.8 gallons/ft2/yr X % propane source]

Quarters

Energy [liters/yr = BGA m2 X 18 liters/m2/yr X % propane source OR gallons/yr = BGA ft2 X 0.29 gallons/ft2/yr % propane source]

OR

January 2024 (13‐4) 76 TN‐X

Fuel Need – Heating Oil (HO)

Inpatient

Energy [liters/yr = BGA m2 X 41 liters/m2/yr X % HO source OR gallons/yr = BGA ft2 X 1.0 gallons/ft2/yr X % HO source]

Outpatient

Energy [liters/yr = BGA m2 X 21 liters/m2/yr X % HO source OR gallons/yr = BGA ft2 X 0.5 gallons/ft2/yr X % HO Source]

Quarters

Energy [liters/yr = BGA m2 X 12 liters/m2/yr X % HO source OR gallons/yr = BGA ft2 X 0.45 gallons/ft2/yr % HO source]

Total Estimated Facility Fuel Requirements

Energy Power

Natural Gas ft3/yr ft3/hr

Propane gal/yr gal/hr

Heating Oil gal/yr gal/hr

Electricity to the site is provided by [Name of utility]. The electrical supply available to the site is [Number] percent of the estimated need. The electrical power available to the site is [Number] percent of the estimated need. [If there are any known issues with the electrical utility variance history, the electrical utility’s rate structure or reliability, Describe Here.] The electrical utility feeder type to the site is a [single radial line OR dual line OR network line]. The project site will [not require an electrical powerline extension OR require an electrical powerline extension of about [Number] [ft OR m] for an estimated cost of $[Number]].

The [natural gas OR propane OR heating oil] to the site is provided by [Name of utility]. The fuel supply available to the site is [Number] percent of the estimated need. The site will [not require a natural gas line extension OR require a natural gas line extension of about [Number] [ft OR m] for an estimated cost of $[Number]].

XIII. INFORMATION TECHNOLOGY (IT) AND DATA SYSTEMS INFRASTRUCTURE

REQUIREMENTS

Health Information Technology (HIT) plays a critical and expanding role in healthcare as technologies including electronic health records, e-care technologies and mobile health technologies become central to expanding access to primary, acute and preventive care, lowering costs and reforming reimbursement incentives.

Telemedicine and remote monitoring applications remove geography and time as barriers to care, allowing instant access with providers and real-time tracking of patient vitals from outside the facility.

The HIT systems, processes and emphasis within IHS facilities are:

• The secure storage, access and exchange of appropriate health information among patients, consumers, providers, government and quality entities, and insurers.

January 2024 (13‐4) 77 TN‐X

• The IHS Electronic Health Record (EHR), the Resource and Patient Management System (RPMS), a decentralized integrated solution for management of both clinical and administrative information.

• The Health Information Exchange (HIE) that collects patient history documents from various sources, facility types and locations for the secure exchange of relevant patient data.

• Telemedicine / Telehealth The primary metric used is Bandwidth available compared to Bandwidth required to site.

Bandwidth is the data transfer rate, usually measured in bits per second (bps), millions of bits per second (megabits per second, or Mbps), or billions of bits per second (gigabits per second, or Gbps). Factors that go into estimating bandwidth requirements are:

• Number of users • Real-time transactions • Storage technology

• Where Users are located

• Hardware

Available Broadband Access Versus Recommended Facility Broadband Access

Available at the Chosen Site Recommended

Bandwidth

Cost/Distance to extend Broadband to site

Broadband Access/ Circuit Type

Reliability (If Known) 99.90%

Latency (If Known) <50 ms primary <120 ms back-up

Jitter (If Known) <20 ms

Packetloss (If Known) <1%

XIV. EMERGENCY RESPONSE

Availability, adequacy and proximity of emergency response services from fire, rescue and police are shown in the table below. Use of the site [will OR will not] result in negative impact the Emergency Response Systems.

January 2024 (13‐4) 78 TN‐X

Emergency Response Systems

Chosen

Distance to Fire Department (miles)

Fire Department Response Time

Distance to Police Department (miles)

Police Response Time

Will site Use result in negative impact on Emergency Response Systems?

XV. ENVIRONMENTAL REVIEW AND DETERMINATION

An [Environmental Assessment OR Environmental Impact Statement OR IHS Environmental Review documentation] was completed and an Agency Environmental Determination was issued on [Date].

Title V projects may include only the determination without the supporting review materials because the Tribe is responsible for all Federal environmental and historic preservation requirements under a Title V Construction Project Agreements.

Edit list below to match the environmental review documents.

The use of the proposed action will not adversely affect:

• An EPA designated sole source aquifer

• A Wilderness Area

• Any federal or applicable state, listed endangered or threatened species or their habitat

• Community noise levels

• A wild, scenic, or recreational river area

• A Coastal Zone in inconsistent with the State Coastal Zone Management Plan

• Park land, other public lands, or areas of recognized scenic or recreational value

• Properties listed, or eligible for listing, on the National Register of Historic Places

• Wetlands and Water Resources (lakes, rivers, ponds, streams, etc.)

500 Year Floodplain The proposed site [is OR is not] located in a 500-year floodplain. The proposed site [is OR is not] located in a 100-year floodplain. The site [is classified as wetlands and will impact the project OR is partially classified as wetlands and will have little or no impact the project OR has no wetlands]. The site [has OR has not] been used for storage or disposal of any hazardous substance. The site [does not have or known to have had OR has underground or above ground storage tanks].

January 2024 (13‐4) 79 TN‐X

Edit below list to match environmental review.

Use of the proposed site will not:

• Conflict with existing or proposed Federal, Tribal, state, and local land use plans

• Require a new wastewater treatment facility that will discharge treated effluent

• Create a need for additional energy supply

• Create a need for additional capacity in educational facilities

• Create a need for additional capacity in transportation systems

• Involve the construction, alteration, or renovation of real property greater than 50 years old

• Require major sedimentation and erosion control measures

• Violate a stormwater or wastewater discharge permit for construction or operations

• Violate or require a Section 404 (Clean Water Act) permit for actions in a wetland

• Violate or require a Section 10 (Rivers and Harbors Act) permit for actions in a stream

XVI. SERVICE AVAILABILITY

[The chosen site has adequate availability of housing, transportation, education, recreation, shopping, dining, and worship services for staff OR [describe services that are absent or lacking]].

***For example, is there a need for staff quarters based on lack of available housing? A search of rental/real estate websites like Zillow can provide a snapshot of the housing market.

Describe amenities within a reasonable distance.

XVII. SUSTAINABILITY

Sustainability features related to site selection that could have an impact on Leadership in Energy and Environmental Design (LEED) certification were considered in the evaluation. The chosen site is:

• Not Public Parkland (SSc1)

• Not Prime Farmland (SSc1)

• Not Threatened or Endangered Habitat (SSc1)

• Not within [100 ft OR 30 m] of a Wetland (SSc1)

• Undeveloped and more than [5 ft OR 1.5 m] above the 100 Year Floodplain (SSc1)

• Undeveloped and more than [50 ft OR 15 m] from a water body (SSc1)

• Developed and has a residential area with 10 of more types of services closer than [2,600 ft OR 800 m]

January 2024 (13‐4) 80 TN‐X

• Within [1,300 ft OR 400 m] of at least two bus Stops (SSc4.1)

• Bicycle Friendly (SSc4.2)

• Large enough to allow open space larger than the building footprint (SSc5.2)

• Feasible for Stormwater Management with the Predevelopment hydrology maintained.

(SSc6.1)

• Feasible for the Capture/Treatment of more than 90 percent of the Average Annual Rainfall (SSc6.2)

• Accessible to existing resources including water, sewer, and power.

Edit above list as appropriate.

XVIII. SECURITY CONSIDERATIONS

The chosen site [is OR is not] sized and of a configuration to permit the building to be located and oriented with a minimum of [15 m OR 50 ft] buffer between the building and parking, roads, drives or other vehicle accessible areas. The topography, landscape and site surroundings [do OR do not] enable natural surveillance which reduces security risks due to the increased threat of apprehension because the site can be seen by people and passing vehicles. The site’s topography [does OR does not] enable natural access control which can limit the opportunity for crime by easily differentiating between public space and private space.

XIX. TECHNICAL EVALUATION (E.G. GEOTECHNICAL INVESTIGATIONS, TRAFFIC

STUDY, ETC.)

Provide any additional detail on the selected site, items that may have bearing on the design, and any envisioned potential problems, considerations and/or alternative solutions to potential problems.

Some additional reports may be added like geothermal, net zero study, traffic study, etc. Include a discussion in the report and add in Appendix.

The sections above validate, update and/or correct the Phase I SSER information. Site specific technical reports including the environmental review material, [list any additional pertinent material] and the geotechnical report are included in the Appendix.

XX. CONCLUSIONS AND RECOMMENDATIONS

Summarize any areas of concern, potential concern, required actions, significant issues identified in the sections above and recommended approaches to identified problems.

Summarize unusual or additional costs that must be added to the project budget, especially those not addressed in the Phase I SSER or those that have increased for some reason since that report was prepared. These costs might include, site preparation, utility services and extensions, soil conditions, drainage problems (on-site or off-site), Archaeological or historic impacts, wildlife impact, etc. Data should be included also for other project related costs, such demolition of existing buildings, and/or asbestos abatement of existing buildings, easements and special access requirements, etc. This important information should be repeated in the executive summary.

January 2024 (13‐4) 81 TN‐X

[Summarize the findings from the above sections. Note particular areas of clearance, concern, and (potential) mitigation. Address recommendation to these areas.]

The selected site is acceptable for the proposed project. All mandatory Executive Orders, regulations, laws, etc. have been met and required clearances obtained.

January 2024 (13‐4) 82 TN‐X

XXI. APPENDIX/TABS

A. MAPS

SERVICE UNIT

LOCAL AREA

SITE PLAN(s)

PROPOSED SITE ACCESS PLAN

ZONING

TOPOGRAPHY

SANITATION

SOILS

FLOODPLAIN

WETLAND

FEMA

DRAINAGE

EASEMENTS

B. TRIBAL RESOLUTIONS

C. BIA VERIFICATION OF PROPOSED SITE AVAILABILITY

D. FLOOD PLAIN CLEARANCE

E. GEOTECHNICAL REPORTS

F. ARCHAEOLOGICAL REPORT

G. CORRESPONDENCE (Utilities)

H. ENVIRONMENTAL ASSESSMENT

January 2024 (13‐4) 83 TN‐X

TAB A MAPS

January 2024 (13‐4) 84 TN‐X

SERVICE UNIT

January 2024 (13‐4) 85 TN‐X

LOCAL AREA

January 2024 (13‐4) 86 TN‐X

SITE PLAN(s)

January 2024 (13‐4) 87 TN‐X

PROPOSED SITE ACCESS PLAN

January 2024 (13‐4) 88 TN‐X

ZONING

January 2024 (13‐4) 89 TN‐X

TOPOGRAPHY

January 2024 (13‐4) 90 TN‐X

SANITATION

January 2024 (13‐4) 91 TN‐X

SOILS

January 2024 (13‐4) 92 TN‐X

FLOODPLAIN

January 2024 (13‐4) 93 TN‐X

WETLAND

January 2024 (13‐4) 94 TN‐X

FEMA

January 2024 (13‐4) 95 TN‐X

DRAINAGE

January 2024 (13‐4) 96 TN‐X

EASEMENTS

January 2024 (13‐4) 97 TN‐X

TAB B TRIBAL RESOLUTIONS

January 2024 (13‐4) 98 TN‐X

TAB C BIA VERIFICATION OF PROPOSED

SITE AVAILABILITY

January 2024 (13‐4) 99 TN‐X

TAB D FLOOD PLAIN CLEARANCE

January 2024 (13‐4) 100 TN‐X

TAB E GEOTECHNICAL REPORTS

January 2024 (13‐4) 101 TN‐X

TAB F ARCHAEOLOGICAL REPORT

January 2024 (13‐4) 102 TN‐X

TAB G CORRESPONDENCE (Utilities)

January 2024 (13‐4) 103 TN‐X

TAB H ENVIRONMENTAL ASSESSMENT