Charlotte Regional Transportation Planning Organization Demographic Profile Form
The following demographic survey is voluntary and will assist staff in identifying residents that we have reached and helps us work toward our goal of inclusive engagement. Please note that your responses will be used solely for data collection and are optional.
Meeting Type: Equity Focus Group
Date
-
Month
-
Day
Year
Date
Location
In accordance with Title VI of the Civil Rights Act of 1964 and related authorities, the CRTPO assures that no person(s) shall be excluded from participation in, denied the benefits of, or subjected to discrimination under any of the Department’s programs, policies, or activities, based on their race, color, national origin, disability, age, income, or gender. Completing this form helps meet our data collection and public involvement obligations under Title VI and will improve how we serve the public. Please place the completed form in the designated box on the sign-in table, hand it to CRTPO staff or email it to email@crtpo.org.
A summary of all forms will remain on file at the CRTPO as part of thepublic record.
Address Street Name Only (i.e., Main Street)
Street Name Only (i.e., Main Street)
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Age
Less than 18
18-29
30-44
45-64
65 and older
Total Annual Household Income
Less than $12,000
$12,000 – $19,999
$20,000 – $30,999
$31,000 – $46,999
$47,000 – $69,999
$70,000 – $93,999
$94,000 – $117,999
$118,000 or greater
Race/Ethnicity:
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Hispanic/Latino
Other (please specify)
Disabilities: Do you or a member of your household have one or more of the following disabilities?
Yes
No
If yes, check those that apply:
Visually impaired
Hearing impaired
Mobility impaired
Other (please specify)
Language: Main language you use at home:
English
Spanish
Asian& Pacific Islander Languages
Indo-EuropeanLanguages
Vietnamese
Other (please specify)
Vehicles: Number of personal vehicles in your household:
Zero (0)vehicles
One (1) vehicle
Two (2) vehicles
Three (3) vehicles
Four(4) or more vehicles
How did you hear about this meeting? (Email, flyer, news or media,newspaper ad, newsletter, social media, website, or provide other source)
Thank you for your participation!
Submit
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