Section 4(F)/6(F) Determinationrequest Form

Section 4(f)/6(f) DeterminationRequest Form

for Recreational Properties

Project Name
PID
Project Sponsor
Form Preparer
NEPA Document Level
Env. Commitment Date
Date Submitted/Revised
ODOT has been assigned FHWA’s responsiblities pursuant to the Surface Transportation Project Delivery Program, otherwise known as NEPA Assignment. The environmental review, consultation, and other actions required by Section 4(f) of the Department of Transportation Act are being carried out by ODOT pursuant to 23 U.S.C. 327 and a Memorandum of Understanding dated December 11, 2015, and executed by FHWA and ODOT.
Level of 4(f)Determination
No Use / ☐ / Individual Bikeway or Walkway(Programmatic Evaluation) / ☐
de minimis / ☐ / Net Benefit
(Programmatic Evaluation) / ☐
Exception (Type: ______) / ☐ / Individual / ☐
Type of 4(f) Property
Park / ☐ / Wild and Scenic River / ☐
Recreation Area / ☐ / Wildlife and Waterfowl Refuge / ☐
School Playground / ☐ / Wildlife Area / ☐
Trail or Shared Use Path / ☐ / Other: / ☐
Level of 6(f) Determination
No 6(f) / ☐ / Conversion / ☐
Maintenance / ☐ / To Be Determined by ODNR / ☐
Temporary Non-Conforming Use / ☐ / ☐

Project Description

Purpose & Need (Only for de minimis, ProgrammaticorIndividual Evaluations)

Description of 4(f) Property(If multiple properties, include each as a bold heading)

Description of Impacts(If multiple properties, include each as a bold heading)

Alternatives Analysis

(Only for Net Benefit, Individual, Temporary Non-Conforming Use, and Conversions)

4(f)Specific Public Involvement Summary

(Only for de minimis, Programmaticor Individual Evaluation)

Description of Section 6(f) Replacement Property

Section 6(f) Conversion - State Comprehensive Outdoor Recreation Plan (SCORP)

(ODNR use only)

Measures to Minimize Harm/Mitigation/Environmental Commitments

Appendix A

4(f)/6(f) Specific Locational Mapping, Plan Sheets, and Photographs

(Only include plan sheets that illustrate impacts to property)

(Only include photographs that show property and areas of impact)

Appendix B

OWJ Consultation and Concurrence

Appendix C

Easements/Lease Agreements(if applicable)

Appendix D

4(f) Specific Public Involvement

(Do not include items related to overall NEPA PI activities)

Appendix E

Section 6(f)

Items Needed / Small Conversion / Partial Conversion / Full Conversion / Temp Non Conform / Required Item included (Y/N) / Comments
Alternatives Report / X / X / X / X
Complete Description of Acquired Site / X / X / X
Description of Population Served / X / X / X
ODOT Cultural Resources Approval
/ X / X / X / X
Equivalent Recreational Usefulness / X / X / X
History of Acquired Land / X / X / X
Location Map / X / X / X / X
Map of Converted Area within Larger 6(f) Boundary / X / X
New Boundary Map(s) (ODNR will provide) / X / X / X
Owner/Land Manager / X / X / X
SCORP Reference(ODNR will provide) / X / X / X
Length of Time Occupied / X
Waiver Valuations / X
USPAP Appraisals on Both Converted and Replacement Land / X / X
Zip Code / X / X / X / X

Section 4(f)/6(f) Determination Request Form for Recreational Properties

Revised March 2017