Form FEMA Form 009-0-12 FEMA Form 009-0-12 Special Consideration Questions

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
SPECIAL CONSIDERATION QUESTIONS

O.M.B. NO. 1660-0017
Expires July 31, 2016

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average .5 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, 500
C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0017). NOTE: Do not send your completed questionnaire to this address.
APPLICANT

PA ID #
PROJECT #.

PROJECT NAME

DATE

LOCATION

Form must be filled out - for each project.
1. Does the damaged facility or item of work have insurance and/or is it an insurable risk? (e.g., buildings, equipment, vehicles, etc.)
Yes
No
Unsure
Comments

2. Is the damaged facility located within a floodplain or coastal high hazard area/or does ti have an impact on a floodplain or wetland?
Yes
No
Unsure
Comments

3. Is the damaged facility or item of work located within or adjacent to a Coastal Barrier Resource System Unit or an Otherwise Protected rea?
Yes
No
Unsure
Comments

4. Will the proposed facility repairs/reconstruction change the pre-disaster condition? (e.g., footprint, material, location, capacity, use or function)
Yes
No
Unsure
Comments

5. Dose the applicant have a hazard mitigation proposal or would the applicant like technical assistance for a hazard mitigation proposal?
Yes
No
Unsure
Comments

6. Is the damaged facility on the National Register of Historic Places or the state historic listing? Is it older than 50 years? Are there other, similar buildings near
the site?
Yes

No

Unsure

Comments

7. Are there any pristine or undisturbed areas on, or near, the project site? Are there large tracts of forestland?
Yes
No
Unsure
Comments
8. Are there any hazardous materials at or adjacent to the damaged facility and/or item of work?
Yes

No

Unsure

Comments

9.Are there any other environmental or controversial issues associated with the damaged facility and/or item of work?
Yes
No
Unsure
Comments

FEMA FORM 009-0-120

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