OMB No.: 0915-0324 Expiration Date: 7/31/2028

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

HEALTH RESOURCES AND SERVICES

ADMINISTRATION

ENVIRONMENTAL INFORMATION AND

DOCUMENTATION (EID)

Award Recipient Name

Program/Fundin g Opportunity

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) as amended with the Fiscal Responsibility Act (FRA) P.L 118-5 of 2023. 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 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 Notice of Award (NOA). 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 and is valid until 7/31/2028. 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 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

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) mailto:paperwork@hrsa.gov

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 (NOA). 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:

https://msc.fema.gov/portal/home

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 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 America?

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

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

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. Other Federal, State, Local, or Tribal Laws

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

J.1. Will the action convert significant agricultural lands to non-agricultural uses or impact Prime Farmland Soils or

Yes No

If yes explain:

J.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:

J.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:

J.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:

K. Cumulative Impacts

Soils of Statewide Importance?

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.

K.1. Has the area around the project undergone major changes in land use/development?

Yes No

If yes explain:

K.2. Are major changes in land use/development planned for the area around the project?

Yes No

If yes explain:

K.3. Will the action alter the use of other land by related development of stores, roads, or site changes?

Yes No

If yes explain:

L. 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):

Date:

(Award Recipient or responsible, knowledgeable person who completed this document)

Date:

(Award Recipient Authorized Representative)

Public Burden Statement: The purpose of this collection is to specific project and site related information not collected in other application forms to determine the level of review required under the National Environmental Policy Act (NEPA) and related laws. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0324 and it is valid until 7/31/2028. This information collection is required to obtain or retain a benefit (National Environmental Policy Act of 1969 (NEPA) as amended by the Fiscal Responsibility Act (FRA) of 2023; the HHS General Administration Manual Part 30 Environmental Protection procedures). Data will be private to the extent permitted by the law. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Signature (Type Full Name):

Signature (Type Full Name):

Title or Position:

Title or Position:

Phone Number:

Phone Number:

mailto:paperwork@hrsa.gov