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 & and title email (if available) Proposed Amount of funding subproject requested /subgrant Period of (brief description) performance 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. very very Continue on additional page if necessary) adverse adverse Risk or are risk* are are Low specified Significant Adverse possible With Moderate mitigation, impacts High-Risk* Very unknown significant unlikely significant unlikely 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:
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:
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