Title VI Public Involvement Form

2. 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.

4. Project Name
6. Date
   Date
8. Location of Public Meeting
10. Name (optional)
12. Gender

    1. Male
    2. Female
    3. Other
    4. Prefer not to disclose
14. Disability

    1. Yes
    2. No
    3. Prefer not to disclose
16. General Ethnic Identification Categories

    Check as many as apply

    1. Black or African American
    2. Asian
    3. Hispanic or Latino
    4. Caucasian
    5. Native Hawaiian/Pacific Islander
    6. American Indian/Alaskan Native
    7. Other
    8. Prefer not to disclose
18. Country of Birth

    1. Canada
    2. China
    3. Korea
    4. Germany
    5. Japan
    6. Philippines
    7. Mexico
    8. England
    9. USA
    10. Other
    11. Prefer not to disclose
20. Marital Status

    1. Single
    2. Married
    3. Divorced
    4. Widowed
    5. In a domestic partnership
    6. Prefer not to disclose
22. Languages Spoken at Home

    Check as many as apply

    1. English Only
    2. Korean
    3. German
    4. Tagalog
    5. Russian
    6. Arabic
    7. Spanish
    8. Chinese
    9. Vietnamese
    10. Other
    11. Prefer not to disclose
24. Age

    1. Under 18
    2. 18 - 24
    3. 25 - 34
    4. 35 - 44
    5. 45 - 54
    6. 55 - 64
    7. 65 - 79
    8. 80+
    9. Prefer not to disclose
26. Do you identify with any of the following religions?

    1. Judaism
    2. Hinduism
    3. Christianity
    4. Islam
    5. Inter/Non-denominational
    6. Native American
    7. Buddhism
    8. No religion
    9. Other
    10. Prefer not to disclose
28. What is the highest degree or level of education you have completed?

    1. Less than high school
    2. High school graduate
    3. Completed some college
    4. Associate degree
    5. Bachelor's degree
    6. Completed some postgraduate
    7. Master's degree
    8. Ph.D.
    9. Graduate or professional degree
    10. Prefer not to disclose
30. What is your approximate average household income?

    1. Less than $25,000
    2. $25,000 - $49,999
    3. $50,000 - $74,999
    4. $75,000 - $99,999
    5. $100,000 - $124,999
    6. $125,000 - $149,999
    7. $150,000 - $174,999
    8. $175,000 - $199,999
    9. $200,000 and up
    10. Prefer not to disclose
32. Thank you for your participation!
Leave This Blank:


34. Submit

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