HP Reporting Form

OMB Control Number 1910 - 5155

U.S. Department of Energy
HISTORIC PRESERVATION REPORT

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 undertaken with DOE funds:

___________________________

If your answer to question 1c above is “yes” then please answer questions 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, 2c, or 2d, please list the following:

3a. Number of Section 106 reviews completed under the PA:

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.

OMB Control Number 1910 - 5155
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.

OMB Control Number 1910 - 5155

Historic Preservation Report Instructions
Line Item Instructions for the Historic Preservation Report

Item
#

Reporting Item

Historic Preservation
Reporting Period
Grant Number

1a
1b
1c

1d

1e

2a

2b

State where recipient is
located
Name of Recipient
Utilization of U.S. DOE
executed Historic
Preservation Programmatic
Agreement (PA)

Activities for which a PA
was not utilized to meet the
requirements of the National
Historic Preservation Act.
Total number of activities
being funded in whole or in
part with DOE funds
Activities exempt from
further historic preservation
review under the PA due to
property age
Activities exempt from
further historic preservation
review per the PA list of
exempt activities.

Instructions
Recipients must report to DOE through the PAGE system
annually no later than 9/15. The annual reporting period is
8/31 through 9/1.
The grant number begins with four letters followed by 7
numerical digits (e.g. ...DE-EE0000000)
Enter State abbreviation from SF424
Enter Grantee Legal Name from SF424
A Programmatic Agreement (PA) is an agreement covering the
recipients in the State identified in question 1(a) and which is
executed between the United States Department of Energy, the
State Agency Recipient(s) receiving financial assistance from
U.S. DOE for EECBG, WAP, and SEP and the State Historic
Preservation Office.
The term “activities” as used in this report refers to the
individual tasks that comprise a project funded in whole or in
part by U.S.DOE through EECBG, WAP or SEP.
User entry is required and it must be numeric.

(see also, definition of “activities” in the instructions to 1d

above)

User entry is required and it must be numeric.

The PA should identify in a list or Appendix those activities

that are exempt from further historic preservation review. User

entry is required and it must be numeric.

OMB Control Number 1910 - 5155

2c

3

3a

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).
Activities not identified as
exempt from further
review under questions 2a,
2b, 2c, or 2d.
Number of Section 106
reviews completed under
the PA.

User entry is required and it must be numeric.
(Note that the PA executed in your state may not have this
exemption)

If activities are not exempt from further review under at least
one of the categories identified in questions 2a, b, c or d,
then the Recipient is required to conduct a historic
preservation review in accordance with the remaining
Stipulations in the PA.
User entry is required and it must be numeric.