Environmental Impact Assessment Template

• Form Number

• Form Version

• Date Created

  Date

• Prepared By

• Location
  Address

Project Summary

• Project Title

• Site/Location
  Address

• Organization

• Project Lead/Manager

• Contact Information

Project Description

• Goals and Objectives of the Project

• Nature and Scope of the Project

• Target Start Date

  Date

• Target End Date

  Date

• Regulatory Requirements

• Proposed Alternatives (e.g., Location, Timeframe, Activities)

• The succeeding sections will contain Yes-No questions to screen the environmental impacts of the proposed project. Please specify the reason(s) or detail(s) when prompted to do so. Media attachments are also encouraged to further contextualize the explanations provided.

Natural Resources

• Will the proposed project involve actions that will cause physical changes in the topography of the area?

  Yes

  No

  N/A

• Please explain.

• Will the proposed project use natural resources above or below ground such as land, soil, water, materials/minerals, or energy which are non-renewable or in short supply?

  Yes

  No

  N/A

• Please explain.

• Are there any areas on or around the location that contains important, high-quality, or scarce resources which could be affected by the project (e.g., forestry, agriculture, water or coastal areas, fisheries, minerals)?

  Yes

  No

  N/A

• Specify these areas.

Waste

• Will the proposed project produce solid wastes during its construction, operation, or decommissioning?

  Yes

  No

  N/A

• Please explain.

Pollution

• Will the proposed project release pollutants or any hazardous, toxic, or noxious substances to the air?

  Yes

  No

  N/A

• Expound in detail.

• Will it cause noise and vibration or release of light, heat, energy, or electromagnetic radiation?

  Yes

  No

  N/A

• Expound in detail.

• Will it lead to risks of contamination of land or water from releases of pollutants onto the ground or into surface waters, groundwater, coastal waters, or the sea?

  Yes

  No

  N/A

• Expound in detail.

• Are there any environmentally-damaged or polluted areas on or around the location (e.g., where existing legal environmental standards are exceeded) that could be affected by the project?

  Yes

  No

  N/A

• Specify these areas.

Population

• Will there be any risk of major accidents (including those caused by climate change, in accordance with scientific knowledge) at any phase of the project?

  Yes

  No

  N/A

• Please explain.

• Will the proposed project present a risk to the population (having regard to population density) and their human health during construction, operation, or decommissioning? (e.g., due to water contamination or air pollution)

  Yes

  No

  N/A

• Please explain.

Water Resources

• Are there any water resources including surface waters (e.g., rivers, lakes/ponds, coastal or underground waters) on or around the location that could be affected by the project, particularly in terms of their volume and flood risk?

  Yes

  No

  N/A

• Specify these resources.

Biodiversity

• Are there any protected areas (designated or classified, non-designated or non-classified) for their terrestrial, avian, and marine ecological value, located on or around the location, and which could be affected by the project? <br><br>Examples:<br>• Wetlands<br>• Watercourses <br>• Other water bodies<br>• Coastal zones <br>• Mountains<br>• Forests or woodlands<br>• Undesignated nature reserves or parks

  Yes

  No

  N/A

• Specify these areas and their designation/classification (if applicable).

• Could any protected, important, or sensitive species of flora or fauna that use areas on or around the site (e.g., for breeding, nesting, foraging, resting, over-wintering, or migration) be affected by the project?

  Yes

  No

  N/A

• Please specify.

Transport and Access

• Are there any routes on or around the location which is used by the public for access to recreation or other facilities, which could be affected by the project?

  Yes

  No

  N/A

• Please specify.

• Are there any transport routes on or around the location that are susceptible to congestion or can cause environmental problems, which could be affected by the project?

  Yes

  No

  N/A

• Please specify.

Land Use

• Are there existing land uses or community facilities on or around the location which could be affected by the project? <br><br>Examples:<br>• Housing<br>• Densely populated areas<br>• Industry or commerce<br>• Farm or agricultural holdings <br>• Forestry<br>• Tourism, <br>• Mining and quarrying<br>• Facilities relating to health, education, places of worship, leisure, sports, or recreation

  Yes

  No

  N/A

• Please specify.

• Are there any plans for future land uses on or around the location which could be affected by the project?

  Yes

  No

  N/A

• Please specify.

Climate and Land Stability

• Is the location susceptible to earthquakes, subsidence, landslides, erosion, or extreme/adverse climatic conditions (e.g., temperature inversions, fogs, severe winds) which could cause the project to present environmental problems?

  Yes

  No

  N/A

• Please specify.

Cumulative Effects

• Could this project, together with existing and/or approved developments, result in the cumulation of impacts together during the construction or operation phase?

  Yes

  No

  N/A

• Please explain.

• Assessment Result

  Select Likely to have significant effects on the environment Not likely to have significant effects on the environment Further information required

  • Likely to have significant effects on the environment
  • Not likely to have significant effects on the environment
  • Further information required

• Conclusion

• Recommended Action(s)

• Name and Signature of Assessor

  Sign