Title VI Public Involvement

Title VI of the Civil Rights Act of 1964 requires recipients of federal financial assistance to guarantee its programs and activities provide for effective participation by persons who may be impacted by the City’s transportation decisions.

As participants in the public involvement process, we need your help in gathering demographic information. Completing the form will enable us to document whether our public involvement process includes the affected populations. Completing the form is voluntary; you are not required to complete the form to participate in this meeting.

We will handle the information gathered as confidentially as possible. For further information regarding this process please contact the Title VI Coordinator

Please respond to the following questions:
Project Name
Date

MonthDayYear
Date
Location of Public Meeting
Name (Optional) (Please print)
Gender

MaleFemaleOtherPrefer not to disclose
Disability

YesNoPrefer not to disclose
General Ethnic Identification Categories (check as many as apply):

Black or African AmericanAsianHispanic or LatinoCaucasianNative Hawaiian/Pacific IslanderAmerican Indian/Alaskan NativePrefer not to disclose
Country of Birth

CanadaChinaKoreaGermanyJapanPhilippinesMexicoEnglandUSAPrefer not to discloseOther
What is your Marital Status?

SingleMarriedDivorcedWidowedIn a domestic partnershipPrefer not to disclose
Language Spoken at Home (Check as many as apply)

English OnlyKoreanGermanTagalogRussianArabicSpanishChineseVietnamesePrefer not to discloseOther
Age

Under 1818-2425-3435-4445-5455-6465-7980Prefer not to disclose
Do You Identify with any of the Following Religions?

JudaismHinduismChristianityIslamInter/Non-denominationalNative AmericanBuddhismNo ReligionPrefer not to discloseOther
What is the Highest Degree, or Level of Education you have Completed?

Less than high schoolHigh school graduateCompleted some collegeAssociate degreeBachelor’s degreeCompleted some postgraduateMaster’s degreePh.D.Graduate or professional degreePrefer not to disclose
What is Your Approximate Average Household Income?

Less than $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$124,999$125,000-$149,999$150,000-$174,999$175,000-$199,999$200,000 and upPrefer not to disclose
Please verify that you are human*
Thank you for your paticipation!
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