**NEPA COMPLIANCE CHECKLIST**

**State: Federal Financial Assistance Grant/Agreement/Amendment
Number:**

**Grant/Project Name:**

**This proposal [is]{.underline}; [is not]{.underline} completely
covered by categorical exclusion \_\_\_\_\_ in 516 DM 2, Appendix
\_\_\_\_\_; and/or 516 DM 6, Appendix \_\_\_\_\_.**

(*check ( ) one*) *(Review proposed activities. An appropriate
categorical exclusion must be identified [before]{.underline} completing
the remainder of the Checklist. If a categorical exclusion cannot be
identified, or the proposal cannot meet the qualifying criteria in the
categorical exclusion, or an extraordinary circumstance applies (see
below), an EA must be prepared.)*

**[Extraordinary Circumstances]{.underline}:**

**Will This Proposal** (*check ( ) yes or no for each item below)*:

[Yes]{.underline} [No]{.underline}

1.  1\. Have significant adverse effects on public health or safety.

2.  2\. Have significant adverse effects on such natural resources and
    unique geographic characteristics as historic or cultural resources;
    park, recreation or refuge lands; wilderness areas; wild or scenic
    rivers; national natural landmarks; sole or principal drinking water
    aquifers; prime farmlands; wetlands (Executive Order 11990);
    floodplains (Executive Order 11988); national monuments; migratory
    birds (Executive Order 13186); and other ecologically significant or
    critical areas under Federal ownership or jurisdiction.

3.  3\. Have highly controversial environmental effects or involve
    unresolved conflicts concerning alternative uses of available
    resources \[NEPA Section 102(2)(E)\].

4.  4\. Have highly uncertain and potentially significant environmental
    effects or involve unique or unknown environmental risks.

5.  5\. Have a precedent for future action or represent a decision in
    principle about future actions with potentially significant
    environmental effects.

6.  6\. Have a direct relationship to other actions with individually
    insignificant but cumulatively significant environmental effects.

7.  7\. Have significant adverse effects on properties listed or
    eligible for listing on the National Register of Historic Places as
    determined by either the bureau or office, the State Historic
    Preservation Officer, the Tribal Historic Preservation Officer, the
    Advisory Council on Historic Preservation, or a consulting party
    under 36 CFR 800.

8.  8\. Have significant adverse effects on species listed, or proposed
    to be listed, on the List of Endangered or Threatened Species, or
    have significant adverse effects on designated Critical Habitat for
    these species.

9.  9\. Have the possibility of violating a Federal law, or a State,
    local, or tribal law or requirement imposed for the protection of
    the environment.

10. 10\. Have the possibility for a disproportionately high and adverse
    effect on low income or minority populations (Executive Order
    12898).

11. 11\. Have the possibility to limit access to and ceremonial use of
    Indian sacred sites on Federal lands by Indian religious
    practitioners or significantly adversely affect the physical
    integrity of such sacred sites (Executive Order 13007).

12. 12\. Have the possibility to significantly contribute to the
    introduction, continued existence, or spread of noxious weeds or
    non-native invasive species known to occur in the area or actions
    that may promote the introduction, growth, or expansion of the range
    of such species (Federal Noxious Weed Control Act and Executive
    Order 13112).

*(If any of the above extraordinary circumstances receive a
"[Yes]{.underline}" check () , an EA must be prepared.)*

Yes No This grant/project includes additional information supporting the
Checklist.

**[Concurrences/Approvals]{.underline}**:

Project Leader:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State Authority Concurrence:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(with financial assistance signature authority, if applicable*)

*Within the spirit and intent of the Council of Environmental Quality\'s
regulations for implementing the National Environmental Policy Act
(NEPA) and other statutes, orders, and policies that protect fish and
wildlife resources, I have established the following administrative
record and have determined that the grant/agreement/amendment*:

1.  **is a categorical exclusion as provided by 516 DM 6, Appendix 1
    and/or 516 DM 2, Appendix 1. No further NEPA documentation will
    therefore be made.**

2.  **is not completely covered by the categorical exclusion as provided
    by 516 DM 6, Appendix 1 and/or 516 DM 2, Appendix 1.** **An EA must
    be prepared.**

**[Service signature approval:]{.underline}**

RO or WO Environmental Coordinator:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Staff Specialist, Division of Federal Assistance:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(or authorized Service representative with financial assistance
signature authority)

FWS Form 3-2185 OMB Control Number 1018-0110

Revised 02/2004 Expiration Date 06/30/2007

> OMB Control Number 1018-0110
>
> Expiration Date 06/30/2007

**NOTICE**

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501et seq.),
please be advised that:

1.  

The gathering of information from potential grant recipients is
authorized by The National Environmental Policy Act (NEPA, 42 U.S.C.
4321-4347). NEPA requires that a number of items be considered prior to
any activity under a grant.

2.  The submission of requested information is required for entities
    competing for federal assistance grants . This completed checklist
    is a record that these NEPA issues were considered prior to
    commencing grant activity.

3.  You are not required to respond to a collection of information
    unless it displays a currently valid OMB control number.

4.  This information collection has been approved by OMB and assigned
    clearance number 1018-0110.

5.  The requested information may be subject to disclosure under
    provisions of the Freedom of Information Act (5 U.S.C. 552).

The public reporting burden for the information collected on this form
is 30 minutes. This burden estimate includes time for reviewing
instructions, gathering data, and completing and reviewing form.
Comments on this form should be mailed to the Information Collection
Officer, Mail Stop 222, Arlington Square, U.S. Fish and Wildlife
Service, Washington, DC 20240. Thank you.