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Agency Use Only [If applicable]
Project:
Date:
Short Environmental Assessment Form
Part 2 - Impact Assessment
Part 2 is to be completed by the Lead Agency.
Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by
the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by
the concept “Have my responses been reasonable considering the scale and context of the proposed action?”
No, or
small
impact
may
occur
Moderate
to large
impact
may
occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations?
2.Will the proposed action result in a change in the use or intensity of use of land?
3.Will the proposed action impair the character or quality of the existing community?
4.Will the proposed action have an impact on the environmental characteristics that caused the
establishment of a Critical Environmental Area (CEA)?
5.Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit, biking or walkway?
6.Will the proposed action cause an increase in the use of energy and it fails to incorporate
reasonably available energy conservation or renewable energy opportunities?
7.Will the proposed action impact existing:
a. public / private water supplies?
b. public / private wastewater treatment utilities?
8.Will the proposed action impair the character or quality of important historic, archaeological,
architectural or aesthetic resources?
9.Will the proposed action result in an adverse change to natural resources (e.g., wetlands,
waterbodies, groundwater, air quality, flora and fauna)?
10.Will the proposed action result in an increase in the potential for erosion, flooding or drainage
problems?
11.Will the proposed action create a hazard to environmental resources or human health?
Page 2 of 2
For every question in Part 2 that was answered “moderate to large impact may occur”, or if there is a need to explain why a
particular element of the proposed action may or will not result in a significant adverse environmental impact, please
complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that
have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency
determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting,
probability of occurring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short-
term, long-term and cumulative impacts.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
_________________________________________________ _______________________________________________
Name of Lead Agency Date
_________________________________________________ _______________________________________________
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
_________________________________________________ _______________________________________________
Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer)
Short Environmental Assessment Form
Part 3 Determination of Significance
Agency Use Only [If applicable]
Project:
Date: