Title VI Compliance Assessment Tool

1. Agency Information
  Organization Name:
  Contact:
  Email:
  Phone:
 
2. Does your agency have a signed Title VI Policy Statement? (Click here for more information)  
   Yes     No  
  a. Provide a link to the agency’s Title VI Policy Statement, if applicable.  
   
 
3. Does your agency have a signed Title VI Assurance? (Click here for more information)  
   Yes     No  
  a. Provide a link to the agency’s Title VI Assurances, if applicable.  
   
 
4. Does your agency have a current Title VI/Nondiscrimination Plan? (Click here for more information)  
   Yes     No  
  a. If so, is the plan available online to the general public?  
   Yes     No  
  b. Provide a link to the Title VI Plan, if applicable.  
   
 
5. Does your agency have a Title VI Coordinator? (Click here for more information)  
   Yes     No  
  a. Provide contact information for the Title VI Coordinator (name, physical address, phone number, email).  
  Name:
  Department:
  Physical Address:
  City:
  State:
  Zip Code:
  Phone:
  Email:
  b. Does your agency's Title VI/Nondiscrimination Plan provide an organizational chart that includes the agency's Title VI Coordinator and a description of their responsibilities.  
   Yes     No  
 
6. Does your agency have an external discrimination complaint handling and processing procedure? (Click here for more information)  
   Yes     No  
  a. If so, provide a link to the external discrimination complaint handling protocols.  
   
 
7. Does your agency include Title VI contract provisions in solicitations, contracts and awards? (Click here for more information)  
   Yes     No  
 
8. How does your agency ensure that Limited English Proficient (LEP) individuals have access to the agency’s programs and services? (Requirements are described under the four factor analysis in Executive Order 13166. Additional resources are found at www.lep.gov) (Click here for more information)  
 
  • Completed Language Assistance Plan
  • Contract services for interpretation and translation
  • Focused LEP outreach during planning & construction
  • Identified bilingual employees
  • Other. Please explain:
 
 
9. What outreach efforts does your agency utilize to solicit input from minority populations within your jurisdictional boundaries in order to ensure nondiscrimination in its public participation process? (Click here for more information)  
 
  • Maintaining a Public Participation Plan
  • Targeted community engagement
  • Committees or advisory groups
  • Other. Please explain:
 
 
10. Recipients of federal funds are required to collect and analyze demographic data to ensure nondiscrimination and equity for beneficiaries of programs, services and activities. Identify the data collection sources for analyzing demographic data in the areas within your jurisdictional boundaries. (Click here for more information)  
 
  • Census
  • American Community Survey
  • Department of Education
  • Community Development Offices
  • Other Sources. Please identify:
 
 
11. How does your agency advise the public of Title VI/Nondiscrimination policies and procedures? Note: Electronic placement on a website alone is not enough. (Click here for more information)  
 
  • Agency Web Page
  • Social Media
  • Displayed in Public Building
  • Public Meetings & Outreach
  • Accessible Publications
  • Other. Please specify: