Form FEMA Form 009-0-91 FEMA Form 009-0-91 Project Worksheet

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0017
Expires April 30, 2013

PROJECT WORKSHEET

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.30 hours per response. The burden estimates includes time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this
form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on 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, 1800 South Bell Street, Arlington, VA
20598-3005, Paperwork Reduction Project (1660-0017). NOTE: Do not send your completed questionnaire to this address.
DISASTER
FEMA -

PROJECT NO.

PA ID NO.

DATE

CATEGORY

-DRWORK COMPLETE AS OF

DAMAGED FACILITY

:
APPLICANT

%

COUNTY

LOCATION

LATITUDE

LONGITUDE

DAMAGE DESCRIPTION AND DIMENSIONS

SCOPE OF WORK

Does the Scope of Work change the pre-disaster conditions at the site?
Special Considerations issues included?
Is there insurance coverage on this facility?
ITEM

CODE

YES
YES
NARRATIVE

NO
NO

YES

NO

Hazard Mitigation proposal included?
PROJECT COST
QUANTITY/UNIT

UNIT PRICE

TOTAL COST
PREPARED BY

TITLE

SIGNATURE

APPLICANT REP.

TITLE

SIGNATURE

FEMA Form 009-0-91, (4/2010)

PREVIOUS EDITION OBSOLETE

YES

NO

COST

PROJECT WORKSHEET
INSTRUCTIONS
The Project Worksheet must be completed for each identified damaged project. A project may include damages for more than one site.
After completing all Project Worksheets, submit the worksheets to your Public Assistance Coordinator.
Identifying Information
Disaster: Indicate the disaster declaration number as established by FEMA (i.e., "FEMA 1136-DR-TN", etc.).
Project No.: Indicate the project designation number you established to track the project in your system (i.e., 1,2,3, etc.).
PA ID No.: Indicate your Public Assistance identification number in this space. This is optional.
Date: Indicate the date the worksheet was prepared in MM/DD/YY format.
Category: Indicate the category of the project according to FEMA specified work categories (i.e., A,B,C,D,E,F,G). This is optional.
Applicant: Name of the government or other legal entity to which the funds will be awarded.
County: Name of the county where the damaged facility is located. If located in multiple counties, indicate "Multi-County."
Damage Facility: Identify the facility and describe its basic function and pre-disaster condition.
Work Complete as of: Indicate the date the work was accessed in the format of MM/DD/YY and the percentage of work completed to that
date.
Location: This item can range anywhere from an "address," "intersection of ...," "1 mile south of...on...," to "county wide." If damages are in
different locations or different counties, please list each location. Include latitude and longitude of the project if known.
Damage Description and Dimensions: Describe the disaster-related damage to the facility, including the cause of the damage and the
area of components affected.
Scope of Work: List work that has been completed and work to be completed, which is necessary to repair disaster-related damage.
Does the Scope of Work change the pre-disaster conditions of the site: If the work described under the Scope of Work changes the site
conditions (i.e., increases/decreases the size or function of the facility or does not replace damage components in kind with like materials),
check (x) Yes. If the Scope of Work returns the site to its pre-disaster configuration, capacity and dimensions, check (x) No.
Special Considerations: If the project includes insurable work, and/or is affected by environmental (NEPA) or historic concerns, check (x)
either the Yes or No box so that appropriate action can be initiated to avoid delays in funding. Refer to Applicant Handbook for further
information.
Hazard Mitigation: If the pre-disaster conditions at the site can be changed to prevent or reduce the disaster-related damage, check (x) Yes.
If no opportunities for hazard mitigation exist, check (x) No. Appropriate action will be initiated and avoid delays in funding. Refer to Applicant
Handbook for further information.
Is there insurance coverage on this facility: Federal law requires that FEMA be notified of any entitlement for proceeds to repair disasterrelated damages from insurance or any other source. Check (x) Yes if any funding or proceeds can be received for the work within the Scope
of Work from any source besides FEMA.
Project Cost
Item: Indicate the item number on the column (i.e., 1,2,3, etc.). Use additional forms as necessary to include all items.
Code: If using the FEMA cost codes, place the appropriate number here.
Narrative: Indicate the work, material or service that best describes the work (i.e., "force account labor overtime," "42 in. RCP," "sheet rock
replacement," etc.).
Quantity/Unit: List the amount of units and the unit of measure ("48/cy," "32/lf," "6/ea," etc.).
Unit Price: Indicate the price per unit.
Cost: This item can be developed from cost to date, contracts, bids, applicant's experience in that particular repair work, books that lend
themselves to work estimates, such as RS Means, or by using cost codes supplied by FEMA.
Total Cost: Record total cost of the project.
Records Requirements
Please review the Applicant Handbook, FEMA 323 for detailed instructions and examples.
For all completed work, the applicant must keep the following records:
*Force account labor documentation sheets identifying the employee, hours worked, date and location;
*Force account equipment documentation sheets identifying specific equipment, operator, usage by hour/mile and cost used;
*Material documentation sheets identifying the type of material, quantity used and cost;
*Copies of all contracts for work and any lease/rental equipment costs.
For all estimated work, keep calculations, quantity estimates, pricing information, etc. as part of the records to document the "cost/estimate"
for which funding is being requested.