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* Enter Date of Survey

Date

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* Name of Entity:

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* Name of Title VI Coordinator

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* Completing this survey in response to: (Name of Grant)

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* 1. Is your organization minority-owned or run by minority individuals?

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* If yes, identify the race(s) of the owner or invidual(s) running the organization. (Please see "Definitions of Race & Ethnicity Categories" at the bottom of this survey)**

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* If no, what are the percentages of the racial composition of the board or advisory group? (Please see "Definitions of Race & Ethnicity Categories" at the bottom of this survey)**

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* What steps are being taken to obtain minority representation, if in your geographic service area, minorities represent 5% of the population or more?

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* 2. Nondiscrimination Policies: Does your institution have a written policy stating that services or opportunities will be provided to all persons without regard to race, color, or national origin?

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* 3. Are permanent records kept of all Title VI complaints?

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* 4. In the past 12 months, has your entity/institution received any complaints alleging a Title VI violation? If yes, attach a description of the nature of the complaint and its disposition.

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* 5. Are Title VI information and non-discrimination notices disseminated to your employees or other beneficiaries of services?

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* If yes, describe how employees and/or beneficiaries are informed (posters displayed, brochures displayed, etc.)

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* Do the notices contain contact information if someone has a Title VI or discrimination complaint?

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* 6. Do you have written policies and procedures addressing Title VI?

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* 7. How do you ensure that minorities are effectively made knowledgable about your services?

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* 8. When did you last conduct Title VI training for your staff?

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* How often do you provide the training/refreshment training to your staff?

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* 9. Please indicate, as of this date, the percentages of the racial composition of those that currently receive your program's services. Enter zero if your program does not provide services. (Please see "Definitions of Race & Ethnicity Categories" at the bottom of this survey)**

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* 10. Please indicate as of this date, the percentages of the racial composition of your program's staff. (Please see "Definitions of Race & Ethnicity Categories" at the bottom of this survey)**

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* 11. Please indicate, as of this date, the percentages of the racial composition of your program’s volunteers. Enter zero if your program does not use volunteers. (Please see "Definitions of Race & Ethnicity Categories" at the bottom of this survey)**

Declaration of Applicant:

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* I declare that I have completed the data in this self-survey and to the best of my knowledge and belief, it is true, correct, and complete.

** Definitions of Race & Ethnicity Categories

Race and ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. Definitions of the race and ethnicity categories are as follows:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or more races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

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