Form FEMA Form FF-104-F FEMA Form FF-104-F Applicant Impact Survey

D EPARTMENT OF HOMELAND SECURITY OMB Control Number FF-104-FY-22-235

Federal Emergency Management Agency Expires Month Date Year

APPLICANT IMPACT SURVEY

Paperwork Burden Disclosure Notice Public reporting burden for this data collection is estimated to average 7 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of 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, Paperwork Reduction Project (1660-0017) NOTE: Do not send your completed form to this address.
Privacy Act Statement The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; Title 44 Code of Federal Regulations (C.F.R.) § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public Assistance program.
Purpose and Applicability Applicants complete this form to collect preliminary information regarding incident impacts. FEMA uses this information to assess the Applicant’s incident impacts to identify resources needed to assist the Applicant. FEMA does not use this information to determine the level of funding it provides. For more information, please contact the State, local, Tribal, or Territorial emergency management office for additional information. Recipients and Applicants should use PA Grants Portal to submit all documentation and information to FEMA. Questions are displayed in an intuitive manner to show the information and documentation needed based on answers provided. The following information is needed to complete this form: Applicant-level information Impact information Status of work Estimated cost including insurance information Effects to environmental, floodplain, and historic resources
Section I – Declaration Information1
Declaration # [system generated]	Declaration Date [system generated]			Recipient [system generated]	Region [system generated]
Section II – Applicant Information2
Legal Name [system generated]			FEMA PA ID [system generated]
Section III –Impact Information Applicant will select activities associated with impacts and provide additional information in the sections below based only on selected activities.
Which of the following incident-related activities is the Applicant claiming under FEMA’s Public Assistance program? Select all that apply. ☐ Debris removal3 ☐ Emergency protective measures4 ☐ Infrastructure damage5 ☐ Building code and floodplain management administration and enforcement6 ☐ Administrative costs related to managing Public Assistance awards7
Impact Please identify whether the Applicant has impacts that require immediate attention or federal support. Please select all that apply.						Impacts an underserved community?
☐ Insufficient resources available to conduct emergency protective measures or debris removal.8 Please select the resources not available and provide context about the shortage: ☐ Financial:       ☐ Contract services:       ☐ Equipment:       ☐ Materials:       ☐ Staffing:      						☐ No	☐ Yes
☐ Damaged facilities require temporary relocation of services.9 ☐ Services have already been relocated. Please provide new location:      						☐ No	☐ Yes
☐ Lack of access to: ☐ Populated areas. Please describe:       ☐ Critical facilities. Please describe:       ☐ Potable water. Please describe:      						☐ No	☐ Yes
☐ Operations dependent on temporary equipment due to power outages. Please describe:      						☐ No	☐ Yes
☐ Other. Please describe immediate need:      						☐ No	☐ Yes
Please identify which historically underserved communities within the organization’s jurisdiction are impacted by this incident? 10 ☐ Minority religious groups. Census tract(s):       ☐ Limited access to technology or broadband internet. Census tract(s):       ☐ Low literacy rates. Census tract(s):       ☐ Immigrants. Census tract(s):       ☐ LGBTQ+. Census tract(s):       ☐ Prison populations.11 Census tract(s):       ☐ Rural or geographically disconnected from critical resources. Census tract(s):       ☐ Other. Please describe:       Census tract(s):       ☐ None
What insurance coverage does the Applicant have?12 ☐ Traditional insurance. Please select all that apply and upload insurance policies as applicable: ☐ Property Insurance Policy (Declaration Pages, Schedule of Values, Policy Forms & Endorsements, Inland Marine Section, Equipment Breakdown Section). Please provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Auto Insurance Policy – Commercial (Non-NFIP) Please provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Flood Insurance Policy – National Flood Insurance Program (NFIP) or commercial (Non-NFIP) Please provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Wind Insurance Policy or Wind Pool Please provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Other. Please describe:       and provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Self-insurance or Self-insured Retention Policy. Please describe:       and provide the Policy Period: (MM/DD/YYYY) - (MM/DD/YYYY). Upload insurance policies as applicable. ☐ No insurance Has the Applicant filed a claim? 13 ☐ No. Please select one. ☐ Gathering information to file a claim. Anticipated date of filling: (MM/DD/YYYY) ☐ Insurance does not cover damages from the incident. ☐ Damage or impacts does not exceed the deductible. ☐ Other. Please describe:       ☐ Yes. Has the Applicant received payment or denial? ☐ No ☐ Yes. Please upload correspondence. 14 (optional) How would you describe the debris impacts in your community?15 Please select one. ☐ Significant (e.g., widespread high piles of debris strewn across public and private property) ☐ Moderate (e.g., debris on roads and public property) ☐ Minimal (e.g., some debris clearance but no major debris operations and no debris on private property) Please describe in one or two sentences the debris impacts, including types of debris and approximate quantity if known:      
Has your organization begun work to address impacts and damage? Please select one. ☐ All work is complete. ☐ Work has started and is approximately       % complete. Please provide a projected end date, if known: (MM/DD/YYYY). ☐ Work has not started. Please provide a projected start date, if known: (MM/DD/YYYY). What type(s) of labor does the Applicant intend to use to conduct the work? Please select all that apply. ☐ (Optional) Contractors.16 Please upload procurement policy. ☐ Volunteers ☐ (Optional) Employees.17 Please upload labor policies applicable to the types of staff performing work. ☐ (Optional) Mutual aid.18 Please upload mutual aid agreement. ☐ National Guard ☐ Prison labor ☐ Unsure
What types of facilities were damaged?19 Please select all that apply and provide an approximate number of facilities of each type that were damaged.
☐ Buildings. Approximate number:       ☐ Education ☐ Emergency Services ☐ Housing ☐ Medical ☐ Other. Please describe:       ☐ Transportation. Approximate number:       ☐ Bridges ☐ Mass Transit ☐ Roads/Culverts ☐ Other. Please describe:       ☐ Vehicles or Equipment. Approximate number:      		☐ Natural or Cultural. Approximate number:       ☐ Beaches ☐ Museums ☐ Recreational ☐ Other. Please describe:       ☐ Utilities. Approximate number:       ☐ Communications ☐ Energy ☐ Water or Wastewater ☐ Other. Please describe:       ☐ Water/Flood Control. Approximate number:       ☐ Other. Approximate number:       Please list the other facility types:     
Did the damage occur in an area identified in a climate adaptation plan?20 ☐ No ☐ Yes. Please describe:      

1 Functionality: Generate Declaration #, Declaration Date, Recipient, and Region from Incident Information.

2 Functionality: Generate Legal name and Public Assistance ID # from the Organization Profile.

3 (Help text) Debris includes, but is not limited to: vegetative debris, construction and demolition debris, sand, mud, silt, gravel, rocks, boulders, white goods, vehicle and vessel wreckage.

4 (Help text) Emergency protective measures are activities conducted before, during, or after an incident to eliminate or lessen immediate threats to lives, public health, or safety; or eliminate or lessen immediate threats of significant additional damage to improved public or private property in a cost-effective manner.

5 (Help text) Infrastructure includes built or manufactured buildings, systems, or equipment; or improved and maintained natural features.

6 (Help text) FEMA can provide communities with the resources to administer and enforce building code and floodplain management ordinances following a major disaster declaration through FEMA’s Public Assistance (PA) Program.

7 (Help text) See FEMA Recovery Policy FP 104-11-2 Public Assistance Management Costs (Interim). Functionality: Allow Recipients to complete the Management Cost Project Application. Do not allow a subrecipient to complete a Management Cost Project Application until it has a project obligated.

8 (Help text) Expedited funding: FEMA may provide expedited funding for Emergency Work Projects (Category A or B) that meet or exceed the Large Project threshold. FEMA funds Expedited Projects at 50 percent of the Federal share of the estimated project cost. Requests for Expedited Projects must be submitted to FEMA within 60 days of the Applicant’s Recovery Scoping Meeting. To support its request, the Applicant must provide enough information for FEMA to validate that the work and costs are eligible. FEMA will work to obligate funding within 90 days of receipt of the request. If you are interested in receiving expedited funding for emergency work, please reach out to your Recipient (State, Tribe, or Territory) and indicate interest by choosing this selection.

9 Functionality: Only show this option if emergency protective measures was selected.

10 Functionality: Responses should populate information on the Organization Profile for use on future events.

11 Functionality: Populate based on prison locations.

12 Functionality: Auto-populate responses from Organization Profile.

13 Functionality: Only show question if Applicant indicated they have insurance.

14 (Help text) Please upload documentation when available. It is required prior to submitting a project application.

15 (Help text) Debris includes, but is not limited to, vegetative debris, construction and demolition debris, sand, mud, silt, gravel, rocks, boulders, white goods, and vehicle and vessel wreckage. Functionality: Question only triggered if the Applicant selects debris removal in the Impact Information section.

16 (Help text) Please upload documentation when available. It is required prior to submitting a project application.

17 (Help text) Please upload documentation when available. It is required prior to submitting a project application.

18 (Help text) Please upload documentation when available. It is required prior to submitting a project application.

19 (Help text) For information about funding for resilience opportunities please go to Mitigate Disaster Damage with FEMA Public Assistance. Functionality: Question only triggered if the Applicant selects Infrastructure Restoration in the Impact Information section.

20 (Help text) States and communities around the country have begun to prepare for the climate changes that are already underway. This planning process typically results in a document called a [climate] adaptation plan. Based on this information an adaptation plan can be developed for an organization to prepare and adapt its assets for changes in climate. There are various climate change adaptation frameworks available.

FEMA Form FF-104-FY-22-235 1