Title VI Public Involvement Form

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Title VI Public Involvement Form

  1. 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.

  2. Gender
  3. Disability
  4. General Ethnic Identification Categories

    Check as many as apply

  5. Country of Birth
  6. Marital Status
  7. Languages Spoken at Home

    Check as many as apply

  8. Age
  9. Do you identify with any of the following religions?
  10. What is the highest degree or level of education you have completed?
  11. What is your approximate average household income?
  12. Thank you for your participation!
  13. Leave This Blank: