Form NRCS-PDM-20 Damage Survey Report (DSR)

United States Department of Agriculture
Natural Resources Conservation Service

OMB No. 0578-0030
NRCS-PDM-20

DAMAGE SURVEY REPORT (DSR)
Emergency Watershed Protection Program – Recovery
Section 1A
Date of Report: ______________________
DSR Number: _______________ Project Number: _______________

NRCS Entry Only
Eligible:
YES _____
NO _____
Approved:
YES _____
NO _____
Funding Priority Number (from Section 4) _____
Limited Resource Area: YES ____ NO _____

Section 1B Sponsor Information
Sponsor Name: _____________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________________
Telephone Number: ____________________

Fax: ____________________
Section 1C Site Location Information

County: _______________

State: _______________

Latitude: ______________

Longitude: ______________

Congressional District: _______________
Section: ________ Township: ________ Range: __________

UTM Coordinates: ____________________
Drainage Name: _________________________________________ Reach:___________________________________________
Damage Description: ______________________________________________________________________________________
Section 1D Site Evaluation
All answers in this Section must be YES in order to be eligible for EWP assistance.
Site Eligibility
YES
NO
Damage was a result of a natural disaster?*

Remarks

Recovery measures would be for runoff retardation or soil
erosion prevention?*
Threat to life and/or property?*
Event caused a sudden impairment in the watershed?*
Imminent threat was created by this event?**
For structural repairs, not repaired twice within ten years?**
Site Defensibility
Economic, environmental, and social documentation adequate to
warrant action? (Go to pages 3, 4, 5 and 6 ***)
Proposed action technically viable? (Go to Page 9 ***)

Have all the appropriate steps been taken to ensure that all segments of the affected population have been informed of the EWP
program and its possible effects? YES _____ NO _____
Comments: __________________________________________
* Statutory
** Regulation
*** DSR Pages 3 through 6 and 9 are required to support the decisions recorded on this summary page. If additional space is needed on this or any other page in this
form, add appropriate pages.
1 of 14

Approved XX/XXXX

DSR NO: _______________

Section 1E Proposed Action
Describe the preferred alternative from Findings: Section 5 A:

Total installation cost identified in this DSR: Section 3: $__________

Section 1F NRCS State Office Review and Approval

Reviewed By:

_______________________________________
State EWP Program Manager

Date Reviewed: _______________

Approved By:

_______________________________________
State Conservationist

Date Approved: _______________

PRIVACY ACT AND PUBLIC BURDEN STATEMENT
NOTE: The following statement is made in accordance with the Privacy Act of 1974, (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting the following information is 7 CFR 624 (EWP) and Section 216 of the Flood Control Act of 1950, Public Law 81516, 33 U.S.C. 701b-1; and Section 403 of the Agricultural Credit Act of 1978, Public Law 95-334, as amended by Section 382, of the Federal
Agriculture Improvement and Reform Act of 1996, Public Law 104-127, 16 U.S.C. 2203. EWP, through local sponsors, provides emergency measures
for runoff retardation and soil erosion control to areas where a sudden impairment of a watershed threatens life or property. The Secretary of
Agriculture has delegated the administration of EWP to the Chief of NRCS on state, tribal and private lands.
Signing this form indicates the sponsor concurs and agrees to provide the cost-share to implement the EWP recovery measure(s) determined eligible by
NRCS under the terms and conditions of the program authority. Failure to provide a signature will result in the applicant being unable to apply for or
receive a grant the applicable program authorities. Once signed by the sponsor, this information may not be provided to other agencies. IRS,
Department of Justice, or other State or Federal Law Enforcement agencies, and in response to a court or administrative tribunal.
The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287, 371, 641, 651, 1001; 15 U.S.C. 714m; and 31 U.S.C. 3729 may also
be applicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0578-0030. The time required to complete this information collection is estimated to average 120/2 minutes/hours per response,
including the time for reviewing instructions, searching existing data sources, field reviews, gathering, designing, and maintaining the data needed, and
completing and reviewing the collection information.

USDA NONDISCRIMINATION STATEMENT
''The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age,
disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all
programs.)
Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact
USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination write USDA, Director of Civil Rights, 1400
Independence Avenue, SW, Washington, DC 20250-941 0 or call (800)795-3272 (voice) or (202)720-6382 (TDD). USDA is an equal opportunity
provider and employer.
Civil Rights Statement of Assurance
The program or activities conducted under this agreement will be in compliance with the nondiscrimination provisions contained in the Titles VI and
VII of the Civil Rights Act of 1964, as amended; the Civil Rights Restoration Act of 1987 (Public Law 100-259); and other nondiscrimination statutes:
namely, Section 504 or the Rehabilitation Act of 1973, Title IX of the Amendments of 1972, the Age Discrimination Act of 1975, and the Americans
with Disabilities Act of 1990. They will also be in accordance with regulations of the Secretary of Agriculture (7 CFR 15, 15a, and 15b), which
provide that no person in the United States shall on the grounds of race, color, national origin, gender, religion, age or disability, be excluded from
participation in, be denied the benefits of, or otherwise subjected to discrimination under any program or activity receiving Federal financial
assistance from the U.S. Department of Agriculture or any agency thereof.
2 of 14
Approved XX/XXXX

DSR NO: _______________
Section 2 Environmental Evaluation

2A Resource
Concerns

2B Existing Condition

Proposed Action

2C Alternatives and Effects
No Action

Alternative

2D Effects of Alternatives
Soil

Water
Downstream
water rights

Air

Plant

Animal

Other

3 of 14
Approved XX/XXXX

DSR NO: _______________

Resource
Consideration

Section 2E Special Environmental Concerns
Alternatives and Effects
Existing Condition
Proposed Action
No Action

Alternative

Clean Water Act
Waters of the U.S.
Coastal Zone
Management Areas

Coral Reefs

Cultural Resources
Endangered and
Threatened Species
Environmental
Justice
Essential Fish
Habitat
Fish and Wildlife
Coordination
Floodplain
Management

Invasive Species

Migratory Birds

Natural Areas
Prime and Unique
Farmlands

Riparian Areas

Scenic Beauty

Wetlands
Wild and Scenic
Rivers
Completed By: __________________________________

Date: ________________________
4 of 14
Approved XX/XXXX

DSR NO: _______________
Section 2F Economic
This section must be completed by each alternative considered (attach additional sheets as necessary).
Future Damages ($)

Damage Factor (%)

Near Term Damage
Reduction

Properties Protected (Private)

Properties Protected (Public)

Business Losses

Other

Total Near Term Damage Reduction $
Net Benefit (Total Near Term Damage Reduction minus Cost from Section 3)
Completed By: __________________________________

Date: ________________________

5 of 14
Approved XX/XXXX

DSR NO: _______________

Section 2G Social Consideration
This section must be completed by each alternative considered (attach additional sheets as necessary).
YES

NO

Remarks

Has there been a loss of life as a result of
the watershed impairment?
Is there the potential for loss of life
due to damages from the watershed
impairment?
Has access to a hospital or medical facility
been impaired by watershed impairment?
Has the community as a whole been
adversely impacted by the watershed
impairment (life and property ceases to
operate in a normal capacity)
Is there a lack or has there been a
reduction of public safety due to watershed
impairment?

Completed By: __________________________________

Date: ________________________

6 of 14
Approved XX/XXXX

DSR NO: _______________

Section 2H Group Representation Information
This section is completed only for the preferred alternative selected.
Group Representation
American Indian/Alaska Native Female Hispanic
American Indian/Alaska Native Female Non-Hispanic
American Indian/Alaska Native Male Hispanic
American Indian/Alaska Native Male Non-Hispanic
Asian Female Hispanic
Asian Female Non-Hispanic
Asian Male Hispanic
Asian Male Non-Hispanic
Black or African American Female Hispanic
Black or African American Female Non-Hispanic
Black or African American Male Hispanic
Black or African American Male Non-Hispanic
Hawaiian Native/Pacific Islander Female Hispanic
Hawaiian Native/Pacific Islander Female Non-Hispanic
Hawaiian Native/Pacific Islander Male Hispanic
Hawaiian Native/Pacific Islander Male Non-Hispanic
White Female Hispanic
White Female Non-Hispanic
White Male Hispanic
White Male Non-Hispanic
Total Group

Number

Census tract(s) ________________________________________________________________
Completed By: __________________________________

Date: ________________________

7 of 14
Approved XX/XXXX

DSR NO: _______________
Section 2I. Required consultation or coordination between the lead agency and/or the RFO and another governmental unit
including tribes:
Easements, permissions, or permits:

Mitigation Description:

Agencies, persons, and references consulted, or to be consulted:

8 of 14
Approved XX/XXXX

DSR NO: _______________
Section 3 Engineering Cost Estimate
Completed By: __________________________________

Date: ________________________

This section must be completed by each alternative considered (attach additional sheets as necessary).

Proposed Recovery Measure
(including mitigation)

Quantity

Units

Unit Cost ($)

Amount ($)

Total Installation Cost (Enter in Section 1F)$
Unit Abbreviations:
AC Acre
CY Cubic Yard
EA Each
HR Hour
LF Linear Feet
LS Lump Sum
SF Square Feet
SY Square Yard
TN Ton
Other (Specify)

9 of 14
Approved XX/XXXX

DSR NO: _______________
Section 4 NRCS EWP Funding Priority
Complete the following section to compute the funding priority for the recovery measures in this
application
(see instructions on page 14).
Priority Ranking Criteria

Yes

1. Is this an exigency situation?
2. Is this a site where there is serious, but not immediate threat to human life?
3. Is this a site where buildings, utilities, or other important infrastructure
components are threatened?
4. Is this site a funding priority established by the NRCS Chief?
The following are modifiers for the above criteria
a. Will the proposed action or alternatives protect or conserve federally-listed
threatened and endangered species or critical habitat?
b. Will the proposed action or alternatives protect or conserve cultural sites
listed on the National Register of Historic Places?
c. Will the proposed action or alternatives protect or conserve prime or
important farmland?
d. Will the proposed action or alternatives protect or conserve existing
wetlands?
e. Will the proposed action or alternatives maintain or improve current water
quality conditions?
f. Will the proposed action or alternatives protect or conserve unique habitat,
including but not limited to, areas inhabited by State-listed species, fish and
wildlife management area, or State identified sensitive habitats?

No

Ranking
Number
Plus
Modifier

Modifier

Enter priority computation in Section 1A, NRCS Entry, Funding priority number.

Remarks:

10 of 14
Approved XX/XXXX

DSR NO: _______________
Section 5A Findings
Finding: Indicate the preferred alternative from Section 2 (Enter to Section 1E):

I have considered the effects of the action and the alternatives on the Environmental Economic, Social; the Special
Environmental Concerns; and the extraordinary circumstances (40 CFR 1508.27). I find for the reasons stated
below, that the preferred alternative:
____ Has been sufficiently analyzed in the EWP PEIS (reference all that apply)
Chapter ________
Chapter ________
Chapter ________
Chapter ________
Chapter ________
____ May require the preparation of an environmental assessment or environmental impact statement.
The action will be referred to the NRCS State Office on this date:
NRCS representative of the DSR team
Title: ___________________________________

Date: _________________________

Section 5B Comments:

Section 5C

Sponsor Concurrence: ________________________

Sponsor Representative

Title: ___________________________________

Date: _________________________

Section 6 Attachments:
A. Location Map
B. Site Plan or Sketches
C. Other (explain)

11 of 14
Approved XX/XXXX

INSTRUCTIONS FOR COMPLETING THE NRCS-PDM-20, DSR

Section 1
1A

1B
1C

1D

1E
1F

Section 2

2A

2B

2C

2D

Explanation of Requested Item
Enter Site Sponsor, Location, Evaluation, Selected Alternative, and
Reviewed and Approval Signatures.
Enter the Date, DSR Number, Project Number. For NRCS only enter
Eligible Yes/No, Approved Yes/No, Funding Priority Number, and
Limited Resource Area Yes/No.
Enter Sponsor Name, Address, Telephone, Fax
Enter site location County, State, Congressional District, Latitude,
Longitude, Section, Township, Range, UTM Coordinates, Drainage
Name, Reach within drainage, and Damage Description.
Enter Yes/No and any Remarks for the Site Evaluation information.
Any No response means the site is not eligible for EWP assistance
and no further information is necessary to complete the DSR. (See
NEWPPM 390-502.03 and 390-502-04)
Enter Yes/No regarding whether the affected public has been
informed of the EWP program.
Enter the proposed treatment and the cost of installation.
NRCS Review and Approval.

Who Completes
NRCS completes
with voluntary
assistance from
Sponsor except for
NRCS only portion
of Section 1A.

Explanation of Requested Item
Use available natural resource, economic, and social, information,
including the EWP Programmatic Environmental Impact Statement
(PEIS), to briefly describe the effects of the alternatives to the
proposed action including the “no action” alternative. The no action
alternative is the predicted future condition if no action is taken.
Typically, the proposed action and no action are the alternatives
considered for EWP recovery measures due to the focus on repairing
or preventing damages within a watershed. However, in cases where
additional alternatives are considered, include all pertinent
information to adequately address the additional alternatives (e.g.,
proposed action would be bio-engineering for bank stabilization, no
action alternative, and an additional alternative may be riprap for
bank stabilization).
Do not leave blanks where a consideration is not applicable, use NA
to indicate the factor was considered but not applicable for the
alternative.
List all resource concerns which are relevant to the area of the
proposed action and alternatives. Refer to the National Bulletin 4505-8 TCH-COMPLETING AND FILING MEASEMENT UNITS
FOR RESOURCE CONCERNS IN THE FIELD OFFICE
TECHNICAL GUIDE (FOTG). Note: the affected area may extend
beyond the construction foot print (e. g. where water quality or water
rights are affected downstream of the site.)
Provide a brief description of the present condition of each resource
concern listed in 2A. Quantify conditions where possible.
Reference accompanying photographic documentation.
Briefly summarize the practice/system of practices being proposed,
as well as the “no action” alternative is predicted future condition if
no action is taken.
Document the efforts of the proposed action and alternatives for the
considerations listed in 2A. Reference applicable quality criteria,
information in the CPPE, and quantify effects whenever possible.
Consider both long-term and short-term effects. Consider any
effects which may be individually minor but cumulatively significant
at a larger scale or over an extended time period. Clearly define the
differences between proposed action, no action, and the other
alternatives.

Who Completes
NRCS completes
with voluntary
assistance from
Sponsor.

NRCS only.

12 of 14
Approved XX/XXXX

2E

2F

2G

2H

Enter Special Environmental Concerns for Clean Water Act Waters
of the U.S., Coastal Zone Management Areas, Coral Reefs, Cultural
Resources, Endangered and Threatened Species, Environmental
Justice, Essential Fish Habitat, Fish and Wildlife Coordination,
Floodplain Management, Invasive Species, Migratory Birds, Natural
Areas, Prime and Unique Farmlands, Riparian Areas, Scenic Beauty,
Wetlands, and Wild and Scenic Rivers for each alternative
considered. In the case where the selected alternative from Section
5A impacts a Special Environmental Concern, additional
information, coordination, permitting or mitigation may be required
and adequate documentation should be prepared and attached to the
DSR to identify how NRCS or the Sponsor addressed the concern.
Identify Property Protected both private and public, business losses
and other economic impacts considered for each alternative. Enter
the dollar value of the potential future damages if no action is taken
in the Future Damage (5) column. This would be the estimate of the
value lost if the EWP recovery measure is not installed. Use the
repair cost or damage dollar method to determine the estimate of
future damages. The repair cost method uses the costs to return the
impaired property, good, or services based on their original preevent condition or value. The damage dollar method uses an estimate
of the future damage to value (e.g. if the structure is condemned,
then enter the value of the structure). Enter the estimated amount
based upon existing information or information furnished by the
sponsor, contractors or others with specific knowledge for recovery
from natural disasters for each alternative considered. Often market
values for properties or services can be obtained from personnel at
the local county/parish tax assessment office.
The DSR team needs to determine the Damage Factor (%) which is a
coefficient that indicates the degree of damage reduction to a
property that is attributed to the effect of the proposed EWP
recovery measures. Use an appropriate estimate of how much of the
damage the EWP recovery measure will avoid for the alternative
being considered. If the recovery measures from a single site will
prevent 100 percent of the damage use 100 percent.
The Near Term Damage Reduction is the Future Damage ($) times
the Damage Factor (%). Sum the Near Term Damage Reduction
values to calculate the Total Near Term Damage Reduction.
Enter the Net Benefit which is computed by subtracting the Cost
from section 3 from the total near term damage reduction.
The economic section must be completed for each alternative
considered. Attach additional sheets as necessary.
Enter information to describe the potential social impacts and
considerations for each alternative. Answer Yes or No and any
remarks necessary to adequately address each question.
The information may be obtained through interviews with
community leaders, government officials or sponsors.
Factors such as road closures, loss of water, electricity, access to
emergency services are used when answering whether the
community as a whole has been impaired.
This information is part of the environmental evaluation portion of
the DSR but may be pertinent in Section 4 regarding priorities.
The Social Considerations Section must be completed for each
alternative considered. Attach additional sheets as necessary.
Enter the Group Representation for the preferred alternative. Use
the most recent census tract information based upon where the EWP
recovery measures are located.

Sponsor completes.

13 of 14
Approved XX/XXXX

2I

Section 3

Section 4

Section 5

5A

5B

5C
5D

Section 6

Enter whether easement, permissions, or permits, and mitigation will
require consultation or coordination for the selected alternative (e.g.,
Clean Water Act section 404 permit, Endangered Species Act
section 10 permits, and any State or county permits or requirements).
Describe mitigation to be applied that will offset any adverse
impacts and attach any documentation from other agencies regarding
mitigation requirements.

NRCS completes
with voluntary
assistance from
Sponsor.

Explanation of Requested Item
Enter Proposed Recovery Measure(s) including Quantity, Units, Unit
Cost, and Total Amount Cost.
Enter sum of all Proposed Recovery Measure Costs to calculate
Total Costs. Enter Total Installation Costs in Section 1F.
The Engineering Cost Estimate must be completed for each
alternative considered. Attach additional sheets as necessary.

Who Completes
NRCS completes
with voluntary
assistance from
Sponsor.

Explanation of Requested Item
This section is used to determine the Funding Priority for the
preferred alternative and sequence for initiating recovery measures.
Enter Yes/No for questions 1 through 4 and enter the number
(exigency 1, serious threat to human life 2, etc.) in the right column,
Ranking Number Plus Modifier. Complete the Modifier portion by
placing the alphabetic indicator a. through f. in the Modifier column.
Complete the Ranking Number Plus Modifier column by entering
the alphabetic indictor(s) that exists within the site. The number of
the site designates the priority (e.g., a site with a designation of 2 is a
higher priority that a site with a designation of 3). The modifiers
increase the priority for the same numeric site (e.g., a site with a
designation of 1a, would be a higher priority than a site with a
designation of 1, a site with a designation of 2bc would be a higher
priority than a site designated as 2b). Enter the Funding Priority in
Section 1A.

Who Completes
NRCS completes
with voluntary
assistance from
Sponsor.

Explanation of Requested Item
Enter the Findings, Rationale Supporting Findings, NRCS
Representative signature and Comments, and Concurrence signature
by the Sponsor(s).
Indicate the preferred alternative and check the applicable finding
being made. The NRCS Representative signs indicating the Finding
selected. If the proposed action was adequately addressed in the
PEIS, check all appropriate chapter paragraphs.
Explain the rationale for making the finding. Cite any references,
analysis, data, or documents which support the finding. Add any
additional pages or documents as necessary. To find that an action
has been sufficiently analyzed in an existing NRCS environmental
document, the document must cover an adequate description of the
action proposed for implementation.
Enter any additional Comments.
Sponsor(s) review and concurrence.

Who Completes
NRCS completes.

Include attachments for location map, site sketch or plan and other
information as needed.

NRCS completes
with voluntary
assistance from
Sponsor.

Sponsor(s)
signature.

14 of 14

Approved XX/XXXX