Historic Preservation Report

U.S. Department of Energy

OMB Control No: 1910-5155

HISTORIC PRESERVATION REPORT*

Expiration Date: _________

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*The questions below are hard copy representations of the questions that will be made available in PAGE

Summary Report

Grant Number:
Period:
Includes Unsubmitted Reports:

Total Activities Using DOE Funds (1e):

YES

NO

N/A

Utilized DOE-executed Programmatic Agreement (1c):
Complied with NHPA Req's for non-PA Activities (1d):

Total Exemptions Due to Age (2a):
Total Exemptions Per PA List (2b):
Total Exemptions Under CDBG Agreement (2c):
Total Reviews Completed (3a):

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U.S. Department of Energy

OMB Control No: 1910-5155

HISTORIC PRESERVATION REPORT*

Expiration Date: _________

Historic Preservation Reporting Period:
Grant Number:

1a. State where recipient is located:
1b. Name of Recipient:

1c. Have you utilized a U.S. DOE-executed Historic Preservation Programmatic Agreement (PA) in order to comply with
National Historic Preservation Act requirements for all or some of your U.S. DOE-funded EECBG, WAP, or SEP activities?
Yes

No

1d. If your answer to 1c above is no, then for any activities for which you did NOT utilize a PA for historic
preservation review have you otherwise complied with National Historic Preservation Act requirements for those
activities?
Yes
No
N/A

1e. Total number of activities being funded in whole or in part
with DOE funds:

If your answer to question 1c above is "Yes", then please answer question 2a through 3a
2a. Identify the number of activities that were exempt from further historic preservation review under the PA due
to property age:

2b. Identify the number of activities exempt from further historic preservation review per the PA list of exempt
activities:
2c. Identify the number of activities exempt from further historic preservation review under the PA due to a prior
review under a Section 106 Agreement for Community Development Block Grants (CDBG):

3. For any activities that you did not identify as exempt from further review under questions 2a, 2b, or 2c, please
list the following:
a. Number of Section 106 reviews completed under the PA:

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U.S. Department of Energy

OMB Control No: 1910-5155

HISTORIC PRESERVATION REPORT*

Expiration Date: 09/30/2015

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to verify compliance with Section 106 of the National Historic Preservation Act
(NHPA). The data you supply will be used to demonstrate that projects implemented through the Department of
Energy’s (DOE) Office of Weatherization and Intergovernmental Programs are not adversely effecting historic
properties pending compliance with Section 106.
Public reporting burden for this collection of information is estimated to average 2 hrs per response for WAP
recipients, 4 hours per response for SEP recipients and 2 hrs per response for EECBG recipients, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief
Information Officer, Records Management Division, IM-11, Paperwork Reduction Project (1910-5155), U.S.
Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of
Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5155), Washington, DC 20503.

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