STIP #-#### _______ County SHORT FORM Community Impact Assessment Executive Summary Existing Median: Yes/No Division: Existing No. of Lanes: Planner, firm: Addition of Median(s): ncdot/local PROJECT Proposed No. of WBS: MANAGER: Yes/No PROJECT TYPE: Existing control of access: Proposed control of access: Document TYPE: dIVISION No Control No Control nepa Central Sepa Partial Control Partial Control Program PROJECT (LAPp) Limited Control Limited Control CS PROJECT reviewer Full Control Full Control (IF APPLICABLE): project description: Community Context Vicinity Map Insert a community context narrative here, usually one to two paragraphs Notable Characteristics Bulleted item Bulleted item etc. Potential Project Impacts Bulleted item Bulleted item etc. Recommendations Bulleted item Bulleted item etc. Indirect and Cumulative Effects Statement Bulleted item Community Context Map Insert Community Context Map Community Characteristics, Impacts & Recommendations Community Resource Presence YES, SEPA Parks & Recreation recreational resource(s) or activity YES, NEPA potential 4(f); adjacent Presence to/accessed from the project corridor
STIP #-#### _______ County SHORT FORM Community Impact Assessment Executive Summary Planner, firm: Division: Existing No. of Lanes: Existing Median: Yes/No ncdot/local PROJECT MANAGER: WBS: Proposed No. of Addition of Median(s): Yes/No Document TYPE: nepa Sepa PROJECT TYPE: dIVISION Central Program PROJECT (LAPp) Existing control of access: No Control Partial Control Limited Control Full Control Proposed control of access: No Control Partial Control Limited Control Full Control CS PROJECT reviewer (IF APPLICABLE): project description: Community Context Vicinity Map Insert a community context narrative here, usually one to two paragraphs Notable Characteristics Bulleted item Bulleted item etc. Potential Project Impacts Bulleted item Bulleted item etc. Recommendations Bulleted item Bulleted item etc. Indirect and Cumulative Effects Statement Bulleted item Community Context Map Insert Community Context Map Community Characteristics, Impacts & Recommendations Community Resource Presence recreational resource(s) or activity Presence YES, SEPA Parks & Recreation YES, NEPA potential 4(f); adjacent to/accessed from the project corridor
CIA%20Short-Form%20Template%206-14-18.docx