HomeMy Public PortalAboutTitle VI Public Involvement SurveyCITY OF RICHMOND
OFFICE OF HUMAN RESOURCES AND COMPLIANCE
50 NORTH FIFTH STREET, RICHMOND, INDIANA 47374
PHONE (765) 983-7200 FAX: 765-983-7366
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TITLE VI PUBLIC INVOLVEMENT SURVEY
As a recipient of federal funds, the Indiana Department of Transportation (INDOT) is requiring local agencies to develop
a procedure for gathering statistical data regarding participants and beneficiaries of its federal-aid highway programs and
activities (23 CRF §200.9(b)(4)). The City of Richmond is distributing this voluntary survey to fulfill that requirement to
gather information about the populations affected by proposed projects.
You are not required to complete this survey. Submittal of this information is voluntary. This form is a public document
that the City of Richmond will use to monitor its programs and activities for compliance with Title VI and the Civil Rights
Act of 1964, as amended and its related statutes and regulations.
If you have questions regarding City of Richmond’s responsibilities under Title VI of the Civil Rights Act of 1964 or the
Americans with Disabilities Act (ADA), please contact Title VI / ADA Coordinator, 50 North 5th Street, Richmond, IN
47374, 765-983-7200 (phone), 765-983-7366 (fax). In addition, please visit the City of Richmond’s website at
http://www.richmondindiana.gov/
You may return the survey by folding it and placing it on the registration table (if you received it at a public hearing or
meeting) or by mailing or faxing it to the address above:
Date:
Project Name:
Proposed Project Location:
Gender: Female Male Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race: (Check one or more)
American Indiana or Alaska Native Asian
Native Hawaiian or Other Pacific Islander White
Black or African-American Multiracial
Age: Disability:
1-21 22-40 Yes
41-65 65+ No
Household Income:
$0-$12,000 $12,001-$24,000 $24,001-$36,000
$36,001-$48,000 $48,001-$60,000 $60,001+