FEMA and FHWA Emergency Relief Funds Reimbursements to State Departments of Transportation (2015)

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304 APPENDIX F Caltrans Damage Assessment Form Instructions Damage Assessment Form Instructions The New DAF format- the Emergency Relief Damage Assessment Form (DAF) has been recreated in Adobe Acrobat Professional v.9 to streamline processing data. Also, users must have Acrobat Reader in order to fill in the form on their computer. Users will be able to save the data in the application form with Reader 8.0 or later and send the file as an attachment to an email. Download free software: http://get.adobe.com/reader/ You can tab from field to field; but if you are not sure exactly what type of data is needed in a particular field you can manually move your cursor over a field, and “hover”, and a tool tip will appear, that will explain what information is needed. The scope of work eligible for ER funds is established on the DAF. After the DAF is completed and signed, the Caltrans District representative is responsible for assuring that copies of the DAF are distributed as indicated at the bottom of the DAF and that the DAF data is entered into the FADS 2.0 database. A revised DAF must be prepared if significant deviations from the prior approved DAF scope are proposed or if a significant quantity change is made. Generally, a significant quantity change is considered for: DAF amount is $100,000 or less and the change is greater than$10,000 and 25%. DAF amount is between $100,000 and $1,000,000 and the change is greater than 15%. DAF amount is greater than $1,000,000 and the change is greater than 10%. Revised DAF requests will be reviewed 2 months. The revised DAF paperwork should be submitted to the ER coordinator 2 weeks prior to the review meeting. [1] DAF Number: The Damage Assessment Form (DAF) number uses the format: AAA-BBBBBB-123-0. FHWA and the Department have agreed to standardize the Damage Assessment Form Numbering format as follows: For State ER Projects: [1A] The first 3 spaces (“AAA”) are for the FHWA Engineer’s first, middle and last initials (or something similar). All 3 spaces must be filled in using alpha characters only. The letter “O” should be replaced with an “X”. No empty spaces! [1B] The next 6 spaces (“BBBBBB”) are used to indicate the agency (abbreviated) which is administering the ER project at the damaged site. Not all spaces are required to be filled in. However, no internal spaces are permitted between characters. For State Highway sites, enter CT followed by the district number as CT01, CT02, (not CT 01) and so on. [1C] The next 3 spaces (“123”) are used to designate the site or location number. All 3 spaces must be filled in with numeric characters only. The entry for the first site for an agency will be “001”. The next DAF for a different site will be “002”, and so on. [D] The last single space entry is to show the DAF revision number. The initial DAF must show a “0” (zero) in this space. If major changes are made to the existing DAF, fill out a revised DAF with the new information, get the DAF signed by FHWA, and change this entry from “0” to “1”. The following is an example of the first revision to the eighteenth DAF for a State Highway site in District 2: ABC-CT02__-018-1 (State Hwy. DAF).

305 Damage Assessment Form Instructions Local Agency Projects: [1A] The first 3 spaces (“AAA”) are for the FHWA Engineer’s first, middle and last initials. If the FHWA Engineer does not attend the site visit for a local agency site, enter the initials of the Caltrans District Local Assistance Engineer who attended, or the Caltrans staff who will be signing the DAF. All 3 spaces must be filled in using alpha characters only. The letter “O” should be replaced with an “X”. No empty spaces! [1B] The next 6 spaces (“BBBBBB”) are used to indicate the agency (abbreviated) which is administering the ER project at the damaged site. Not all spaces are required to be filled in. Start on the left and work to the right, no empty spaces between characters. If an agency doesn’t know their abbreviation, district staff can look it up in LP2000, on the first page in the Route box. Counties use their standard abbreviation followed by CO. i.e. YUBCO (not YUB CO) is Yuba County and CND is Concord. [1C] The next 3 spaces (“123”) are used to designate the site number for a given agency. All 3 spaces must be filled in with numeric characters only. The entry for the site for an agency will be “001”. The next DAF for a different site will be “002”, and so on. [D] The last single space entry is to show the DAF revision number. The initial DAF submitted to FHWA must show a “0” (zero) in this space. If major changes are made to the existing DAF, fill out a revised DAF with the new information and change this entry from “0” to “1”. The following is an example of the third DAF for a local site in the County of Yuba: CBA-YUBCO_- 003-0 (Local Agency DAF). [2] Sheet number: Fill in total number of sheets. [3] Project #s: Enter the seven digit Federal Project number (if known). The following is an example entry: 4321(004) for Emergency Opening (EO) and/or Permanent Restoration (PR) 4321(005). You may not have the project numbers by the time the DAF needs to be submitted to FHWA, these can be filled in later. [4] Disaster No.: Enter the 3-digit Federal Disaster Number (required). The disaster number is CA for California, then the Federal Fiscal Year (which starts on October 1) followed by the event number, starting with 1. The following is an example entry: CA09-1, for the first event in California during FFY 2009. [5] Applicant: Caltrans if State administered, or the name of the City, County or other local agency if locally administered. [6] County: The name of the county where the damage is located. [7] Incident Date: Usually the Governor’s Proclamation date; but it may be the date the damage occurred, or was first discovered. If the site is damaged in more than 1 proclaimed event, write additional incident dates in the Justification box at the bottom of the cost calculation sheet [8] Inspection Date: The date that FHWA or Caltrans (local agency sites) visited the damage site. If there was more than one group inspection, it is best to document the additional dates in the justification area at the bottom of the cost calculation sheet. [9] Location of Damage: Check “Per Site” or “Per Mile”

306 Damage Assessment Form Instructions For damage to be eligible for FHWA funding, the repair estimate must be greater than one of the following criteria: State County City Per site $5,000 $5,000 $5,000 Per mile $15,000 $9,000 $5,000 [10] Federal-aid Highway, map number, and Classification: Enter Y for yes in the box next to “Y for yes…”if the damaged route is eligible. Go to the CSR maps at http://www.dot.ca.gov/hq/tsip/hseb/crs_maps/ to determine if the route is a Fed- aid route. Local Roads and Rural Minor Collectors (grey or yellow) are not eligible for FHWA ER funds. Fill in the Map number from the lower right hand corner of the CRS map, and enter the functional classification type (i.e. Major collector). [11] Name of road/bridge: Enter the name of the road/bridge or route number. [12] PM Begin and PM end: If the route has post mile markers enter that information; if not use a short description such as “.1 mile SO River Intersection.” [13] PM length: Enter the length of the site, in feet. [14] Road/Bridge Data: Fill in bridge # if applicable [15] Type: Enter bridge type. (T-beam, PSPT) [16] Identify State/Local Route Number: Enter route number if applicable. [17] Traveled Way: Enter width of traveled way (two 12’ lanes= 24’), and check traveled way type- Portland cement concrete (PCC), asphalt concrete (AC) or Gravel. [18] Shoulder: Enter width of the shoulder (two 8’ shoulders=8’), and check shoulder type- PCC, asphalt concrete AC or Gravel. [19] Forest Highway? Enter “Y” for Yes or “N” for No. If yes the project may be eligible for ERFO- Emergency Relief Federally Owned, for more information see publication number FLH-04-007 or go online at http://www.efl.fhwa.dot.gov/programserfo.aspx . [19] continued Interstate? Enter “Y” for Yes or “N” for No, if the damage is on the Federal Interstate route system. . [20] Existing ADT: Enter the Average daily traffic (ADT). This number is useful in determining EO versus PR, in some instances. [21] Description of Damage: Use general terms describing dimensions, and cause of damage, i.e. mudslide covering 75 feet of road, due to winter storms.

307 Damage Assessment Form Instructions Emergency Opening (EO) versus Permanent Restoration (PR)- EO funding is for work that is needed for either 1)restoring essential travel, 2) minimizing the extent of damage, or 3) protecting the remaining facilities, ONLY. [22] EO Agency Forces Description of Work: Write a general description of EO repairs made by agency forces, only. No contract work of any type. Ct Work Order # are for State applicant work, and probably will not be known at the field review. EA # may not be known at FHWA submittal time [23], [27], and [33] PE (preliminary Engineering) Costs: Round up to even dollars. Expenses must be justified in the Description of Work. If the PE estimate exceeds 10% of the construction cost, it needs a justification. The justification can be written in the Description of Work area, or on the Narrative page, or in the Justification area at the bottom of the Calculation page. [24], [28], and [34] CE (construction engineering) Costs: Round up to even dollars. Expenses must be justified in the Description of Work. If the CE estimate exceeds 15% of the construction cost it needs a justification. The justification can be written in the Description of Work area, or on the Narrative page, or in the Justification area at the bottom of the Calculation page. [25], [29], and [35] Construction Costs: Round up to even dollars. Write the estimated of the cost for repair work. [26] EO- Contract Description of Work: Write a general description of EO repairs made by any type of contractor. For local agencies- local assistance accounting wants an award package for any work done by a contractor. For shortlist or force account contracts- On a piece of paper state that the work is ER force account contact work. Show the date of the agreement, the type/quantity of work that has been agreed upon, and the agreed price. Show the name of the company and the persons who have entered into the agreement. Have both parties sign and date it. [30] and [36] R/W (right-of-way): Fill any the estimated Right-of –way acquisition expenses and support costs. ER will only fund work outside of the R/W if the following 4 conditions are met: Directly related to the protection of the highway Not eligible for funds from another agency No other agency has responsibility Applicant agrees to accept all future maintenance [31] Subtotal Emergency Opening: If you are filling in the DAF by computer, this will automatically be filled in. The sum of all EO estimated work. Round to up to even dollars. PR Type of Repair: PR work must follow federal contract requirements. [32] Description of PR work and Summary Cost: Mark contract and/or FA (Force Account). For FA a PIF (Public Interest Finding) must be completed. For local agencies see “Local Programs Procedures Manual (LAPM)” Chapter 12 PS&E and Exhibit 12-F Write a general description of the Restoration work needed to repair the damaged facility. The EA# may not be known at FHWA submittal.

308 Damage Assessment Form Instructions [37] Subtotal Permanent Restoration: If you are filling in the DAF by computer, this will automatically be filled in. The sum of all PR estimated work. Round to up to even dollars. [38] PE total: If you are filling in the DF by computer, this will automatically be filled in. Add up the 3 PE totals from above. [39] Eligibility and Local Agency signature and Date: If the applicant is a local agency, the agency will mark eligible and sign and date. For local sites that are less than $5,000- mark the DAF as Ineligible, get a State Engineer signature, and submit the DAFs to CAL EMA for 75% reimbursement, for debris removal. [40] CE total: If you are filling in the DF by computer, this will automatically be filled in. Add up the 3 CE totals from above. [41] Eligibility and State Engineer and Date: The State engineer marks Eligible or Ineligible, signs and dates the DAF. [42] R/W total: If you are filling in the DAF by computer, this will automatically be filled in. Add up the 2 Right-of-way totals from above. [43] Eligibility and FHWA Engineer and Date: The FHWA engineer marks Eligible or Ineligible, signs and dates the DAF. For Local applicants- FHWA signature is only required if there are any Betterments, more than 2 ROW takes, or when paving is more than 50% of the total cost. [44] Construction Total: If you are filling in the DAF by computer, this will automatically be filled in. Add up the 3 Construction totals from above. [45] Total Estimate: If you are filling in the DAF by computer, this will automatically be filled in. Add up all totals from above. [46], [47] and [48] Local, State Engineer & FHWA Engineer: Print the name of the signatures above. [49] DAF Prepared by: Print the name of the person who prepared the DAF. Cost Calculation Page: Local agencies may provide their own spread sheet of calculations, in lieu of this page. Put the DAF # and page # in the upper right hand corner. Check if the calc is for EO local forces, EO contract, or PR. Lump sum will generally only be accepted for non-biddable items such as Mobilization. If you are filling in by computer- it will automatically multiply quantity by unit price, and add up all the items. Justifications/Comments: Use this area to explain high PE and/or CE costs, additional site visit dates, and any other topics. If you do not use this page, save a tree and do not send it as part of the DAF. Photos, Sketches and/or Narrative page: Photos are required with any DAF. Locals may submit photos without this page. Put the DAF# and page # in the upper right hand corner. If you do not use this page, save a tree and do not send it as part of the DAF. Local agencies- Do not include plans, time sheets, Proclamations, Resolutions, or bid packages as part of the DAF.

309 U.S. Department of Transportation Federal Highway Administration- California Division- Title 23 Damage Assessment Form (DAF) DAF No. [1A] - [1B] - [1C] - D Sheet # 1 of [2] Federal Project # EO ER - [3] ( ) Disaster No. CA [4] - PR ER - [3] ( ) Applicant County Incident (mm/dd/yyyy) Inspection [5] [6] [7] [8] Location of Damage: [9] Per Site or Per Mile Federal-aid Highway? [10] Name of Road/Bridge: [11] Y for yes, if no, ineligible for ER funds PM Begin: [12] PM Length: [13] Map No (in feet) PM End: [12] Functional Classification Type: Road/Bridge Data: Bridge No [14] Type: [15] Route # [16] Traveled Way: Width [17] Type: PCC AC Gravel Forest Hwy? Y/N [19] Interstate? Y/N Shoulder: Width [18] Type: PCC AC Gravel Existing ADT: [20] Description of Damage: [21] Eligible Signature Date PE Total [38] Yes N o Local Agency (if applicable): [39] CE Total [40] Yes N o Caltrans: [41] R/W Total [42] Yes N o FHWA*: [43] Construction Total [44] TOTAL ESTIMATE [45] Agency sig. Name (print): [46] FHWA Sig. Name (print): [47] CT signature Name (print): [48] DAF Prepared by (print): [49] Original: Caltrans District Copies: FHWA, Division of Local Assistance(local roads), Federal Resources (state hwy), HQ Major Damage Engineer (state hwy) *Write “N/A” in FHWA signature block if the project has no Federal ER funding or Federal ER funding delegated to the State. FHWA Signature: REQUIRED for all Federal Funded State projects. REQUIRED for any Local Agency projects with 1) any BETTERMENT, 2) more than 2 ROW takes or 3) when paving is more than 50% of the Total Estimated Cost. Reminder: This DAF must be accompanied by photos of the damage. COST ESTIMATE Em er ge nc y O pe ni ng (E O ) Type of Repair Description of Work Cost Summary EO- AGENCY FORCES CT Work Order #(s):________________ ________________________________ EA(s):___________________________ [22] PE [23] CE [24] Construction [25] EO- CONTRACT [26] PE [27] EO EA(s): CE [28] Construction [29] NOTE: Environmental documentation for EO is required. It is generally started after work has begun. R/W [30] Subtotal Emergency Opening [31] Pe rm an en t R es to ra tio n (P R ) PR- CONSTRUCTION FA requires an approved PIF [32] PE [33] Contract FA CE [34] PR EAs Construction [35] NOTE:PRIOR AUTHORIZATION (APPROVED E-76) IS REQUIRED TO PROCEED WITH PERMANENT RESTORATION R/W & CONSTRUCTION R/W [36] NOTE: Environmental clearance for permanent restoration is Subtotal Permanent Restoration [37] conducted through normal Federal-aid procedures