Native American Lands of Interest Scoping Determination

05-08-2020	Wisconsin Department of Transportation

Scoping Determination to be completed by scoping team:

Project ID Click or tap here to enter text.	Project Highway Click or tap here to enter text.

Anticipated Project Schedule:

LET Date Click or tap here to enter text. Start Date Click or tap here to enter text. End Date Click or tap here to enter text.

Project Title: Click or tap here to enter text.

Project Limits: Click or tap here to enter text.

(A map, sketch, plan, or another graphic which clearly illustrates the project's location must be included)

Steps 5 and 6 to be completed in consultation with Region Tribal Liaison:

Does project meet definition of being a Native American Lands of Interest? ☐Yes ☐ No

If YES, then proceed to Step 6

If NO, then proceed to Step 7

Names of Native American Tribes with Land Interests for project: Click or tap here to enter text.

Native American Hiring Provision to be added to project: ☐Yes ☐ No

6.	Will grounds be disturbed with this Project? Disturbed is defined as activity that touches subgrade below the roadway typical section, or any ground surface outside the roadway typical. ☐Yes ☐ No

Documented verifications must occur for this certification.

THPO contacted ☐ Yes ☐ No If No, then Project Certification cannot occur.

Region Environmental Coordinator process initiated? ☐Yes ☐ No If No, then Project Certification cannot occur.

If YES, provide explanation, then proceed to Section 106, FDM Chapter 26 Click or tap here to enter text.

If NO, then proceed to Step 7

7. Required Signatory for Certification that Project Has Been Properly Assessed for Being a Land of Tribal Interest

Region Tribal Liaison Scope Determination Approval : Click or tap here to enter text.

Date: Click or tap here to enter text.