FEMA Applicant Impact Survey

Paperwork Burden Disclosure Notice

Public reporting burden for this data collection is estimated to average 15-30 minutes. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472, Paperwork Reduction Project (1660-0017). NOTE: Do not send your completed form to this address.

Privacy Act Statement

The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406- 407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; 44 C.F.R. § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public Assistance Program.

Instructions

The purpose of this form is to capture preliminary information about the Applicant’s incident impacts. The information on this form helps FEMA understand the severity of the Applicant’s disaster impacts and determine the specific types of staff required to provide the Applicant with effective customer service. FEMA does not use the information to determine the level of financial assistance it will provide. Information you will need: • Estimated cost of all incident-related impacts • Estimated cost of all debris impacts • Estimated cost of all immediate threat impacts • List of insurance policies (if applicable)

Select Disaster Number. Please select one. Note: This survey needs to be filled out for each disaster separately.(Required)

Applicant Name (Political subdivision or eligible applicant)(Required)

Section I – Overall Impacts

1. What is the total anticipated cost to address all incident-related impacts?(Required)

Less than the Large Project Threshold

Between the Large Project Threshold and $1,000,000

$1,000,000 or more

2. Does the Applicant have any of the following incident-related impacts?(Required)

Debris

Emergency response/protective measures

Infrastructure damage

Section II – Specific Impacts

Debris Impacts (Category A)

1. What is the level of debris impacts? Please select one.(Required)

Significant

Moderate

Minimal

Please describe in 1 or 2 sentences the debris impacts, including types of debris and approximate quantity if known:(Required)

2. What is the status of work to address debris impacts? Please select one.(Required)

Work is completed and costs are documented.

Work is completed and costs are not documented.

Work has started. Please provide a projected end date below.

Work has not started.

Estimated Date Debris related work will be completed?(Required)

MM slash DD slash YYYY

3. Does the Applicant anticipate work with the following characteristics? Please select all that apply.(Required)

In a river, lake, or other body of water

Within 200 feet of a waterway, body of water, or wetland

Ground disturbance activities

Removing stumps, trees, or limbs

Root ball extraction for stumps or trees

Near endangered species

Other environmental concerns, please describe below.

Other Enviromental Concerns:(Required)

4. What is the total approximate cost to address debris-related impacts? Please select one.(Required)

Less than the Large Project Threshold

Between the Large Project Threshold and $1,000,000

$1,000,000 or more

Immediate Threat Impacts (Category B)

1. Does the Applicant have any impacts that require immediate attention or federal support? Please select all that apply. Please update with most recent information.(Required)

Operations being conducted from temporary locations due to damaged facilities.

Damaged facilities that require temporary relocation of services.

Operations dependent on temporary equipment (such as generators or mobile boilers).

Inaccessible areas.

Inaccessible facilities.

Other, describe immediate need below.

No.

Other Immediate Needs:(Required)

2. What is the status of emergency response/protective measures? Please select one. Please update with most recent information.(Required)

Work is completed and costs are documented.

Work is completed and costs are not documented.

Work has started. Please provide a projected end date below.

Work has not started.

Estimated Date Emergency Response/Protective Measures related work will be completed?(Required)

MM slash DD slash YYYY

3. Does the Applicant anticipate work with the following characteristics in its emergency response/protective measures? Please select all that apply.(Required)

In a river, lake, or other body of water.

Within 200 feet of a waterway, body of water, or wetland.

Ground disturbance activities.

On facilities over 45 years old.

Near endangered species.

Other environmental concerns. Please describe below.

Other Environmental Concerns:(Required)

4. What is the total approximate cost of emergency response/protective measures? Please select one.(Required)

Less than the Large Project Threshold

Between the Large Project Threshold and $1,000,000

Greater than $1,000,000

Infrastructure Damage (Categories C-G)

1. What types of facilities were damaged? Please select all that apply and provide an approximate number of facilities of each type that were damaged. Provide based on most recent information.

Buildings?(Required)

Education

Emergency Services

Medical

Housing

Other

None

Other Building Types:(Required)

Approximate number of damaged Building facilities:(Required)

Water/Flood Control?(Required)

Yes

Approximate number of damaged Water/Flood Control facilities:(Required)

Natural or Cultural(Required)

Beaches

Museums

Recreational

Other

None

Other Natural or Cultural Types:(Required)

Approximate number of damaged Natural or Cultural facilities:(Required)

Transportation(Required)

Bridges

Roads/Culverts

Mass Transit

Other

None

Other Transportation Types:(Required)

Approximate number of damaged Transportation facilities:(Required)

Utilities(Required)

Communications

Energy

Water or Wastewater

Other

None

Other Utility Types:(Required)

Approximate number of damaged Utility facilities:(Required)

Approximate number of damaged Vehicles or Equipment:(Required)

Other Facility Types and approximate number damaged:(Required)

2. Does the Applicant anticipate work with the following characteristics? Please select all that apply.(Required)

In a river, lake, or other body of water.

Within 200 feet of a waterway, body of water, or wetland.

Ground disturbance activities.

On facilities over 45 years old.

Near endangered species.

Other environmental concerns. Please describe below.

Other Environmental Concerns:(Required)

3. Does the Applicant have any additional information about its infrastructure damage? Please describe.(Required)

4. What is the status of work to address infrastructure damage? Please select one.(Required)

Work is completed and costs are documented.

Work is completed and costs are not documented.

Work has started. Please provide a projected end date below.

Work has not started.

Estimated Date Infrastructure related work will be completed?(Required)

MM slash DD slash YYYY

5. Does the Applicant anticipate pursuing any of the following options for one or more facilities? Please select all that apply.

Change the size, capacity, or interior design of a facility(Required)

Yes

Unsure

Please describe:(Required)

Replace or relocate the facility(Required)

Yes

Unsure

Please describe:(Required)

Abandon a facility and use the funds towards a facility with a different function

Yes

Unsure

Please describe:(Required)

6. What is the total approximate cost to address infrastructure damage? Please select one.(Required)

Less than the Large Project Threshold

Between the Large Project Threshold and $1,000,000

Greater than $1,000,000

Section III – All Impacts

1. Does the Applicant know how it plans to conduct the work to address the impacts? Please select all that apply.(Required)

Yes, the Applicant plans to contract for the work. You will be asked to provide a copy of your procurement policy during the process.

Yes, the Applicant plans to use its own staff for the work. You will be asked to provide a copy of your labor policies during the process.

Yes, the Applicant plans to use donated resources or mutual aid for the work.

No.

Unsure.

2. Does the Applicant have any insurance policies? Please select one.(Required)

Yes, but the Applicant has not filed a claim.

Yes, the Applicant has filed a claim but not received settlement.

Yes, the Applicant has filed a claim and received settlement.

No.

If yes, you will be asked to provide copies of any applicable flood, wind, auto, and/or General Property insurance policies. Ensure that documentation includes the following information: • Property policy declaration pages • Schedule of values/covered locations • Equipment breakdown section • Property policy forms and endorsements • Inland marine coverage section (if applicable)