XXXX Environmental Review Form for XXX Program subprojects/subgrants Follow, but do not submit, the attached instructions. A. Applicant information Organization Parent grant or project Individual contact Address, phone & email and title (if available) Proposed Amount of funding subproject requested /subgrant Period of performance (brief description) Location(s) of proposed activities B. Activities, screening results, and findings Screening result Findings (Step 3 of instructions) (Step 6 of instructions. Complete for all moderate/unknown and high-risk activities ONLY) Proposed activities (Provide DESCRIPTIVE listing. Continue on additional page if necessary) very very Risk or adverse adverse risk* impacts are are specified Low possible Adverse With Significant are High-Risk* Moderate mitigation, Very unknown unlikely unlikely significant significant impacts impacts 1. 2. 3. 4. 5. 6. 7. 8. *These screening results require completion of an Environmental Review Report C. Certification: I, the undersigned, certify that: The information on this form and accompanying environmental review report (if any) is correct and complete.
XXXX Environmental Review Form for XXX Program subprojects/subgrants Follow, but do not submit, the attached instructions. A. Applicant information Organization Parent grant or project Individual contact and title Address, phone & email (if available) Proposed subproject /subgrant (brief description) Amount of funding requested Period of performance Location(s) of proposed activities B. Activities, screening results, and findings Screening result (Step 3 of instructions) Findings (Step 6 of instructions. Complete for all moderate/unknown and high-risk activities ONLY) Proposed activities (Provide DESCRIPTIVE listing. Continue on additional page if necessary) Very Low Risk High-Risk* Moderate or unknown risk* significant adverse impacts are very unlikely With specified mitigation, significant adverse impacts are very unlikely Significant Adverse impacts are possible 1. 2. 3. 4. 5. 6. 7. 8. *These screening results require completion of an Environmental Review Report C. Certification: I, the undersigned, certify that: The information on this form and accompanying environmental review report (if any) is correct and complete.