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 Continue on additional page if necessary) very adverse adverse Risk or risk* are are impacts Low specified possible With Moderate mitigation, Very High-Risk* Significant Adverse unknown significant unlikely significant unlikely are impacts impacts 1. 2. 3. 4. 5. 6. 7. 8.
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.
51109.docx