□ Are Title VI posters prominently displayed? Yes No□ □ Are they in areas where services are provided? Yes No□ □ Are Title VI posters or program brochures available in languages other than English? Yes No□ (If yes, please attach copies of documentation.) Contractors Documentation □ Is information about Title VI disseminated to your contractors, sub-contractors (Third Party Contracts) Yes No□ How? _________________________________________________________________________________________ ______________________________________________________________________________________________ Describe contracting opportunities afforded to socially and economically Disadvantaged Business Enterprises (DBEs). □ Do all sub/third party contracts contain a Title VI Statement of Compliance? Yes No□ (If yes, please attach copies of documentation.) Demographics Documentation Please provide the racial and ethnic demographics of your service area (this information can be obtained at ). Does your service population include ethnic groups representing a 5% safeguard or more of your total population? □ Yes No□ Executive Order 13166 Documentation Are you aware of your agency’s obligation to comply with Executive Order 13166 Limited English Proficiency (LEP)? □ Yes No□ □ Does your organization have a Limited English Proficiency (LEP) plan? Yes No□ How do you ensure persons with LEP can access your services? (Requires a written response) Complaints Documentation □ Does your organization have a written complaint and hearing system for discrimination complaints? Yes No□ (If yes, please attach documentation.)
Are Title VI posters prominently displayed? Yes □ No□ Are they in areas where services are provided? Yes □ No□ Are Title VI posters or program brochures available in languages other than English? Yes □ No□ (If yes, please attach copies of documentation.) Contractors Documentation Is information about Title VI disseminated to your contractors, sub-contractors (Third Party Contracts) Yes □ No□ How? _________________________________________________________________________________________ ______________________________________________________________________________________________ Describe contracting opportunities afforded to socially and economically Disadvantaged Business Enterprises (DBEs). Do all sub/third party contracts contain a Title VI Statement of Compliance? Yes □ No□ (If yes, please attach copies of documentation.) Demographics Documentation Please provide the racial and ethnic demographics of your service area (this information can be obtained at ). Does your service population include ethnic groups representing a 5% safeguard or more of your total population? Yes □ No□ Executive Order 13166 Documentation Are you aware of your agency’s obligation to comply with Executive Order 13166 Limited English Proficiency (LEP)? Yes □ No□ Does your organization have a Limited English Proficiency (LEP) plan? Yes □ No□ How do you ensure persons with LEP can access your services? (Requires a written response) Complaints Documentation Does your organization have a written complaint and hearing system for discrimination complaints? Yes □ No□ (If yes, please attach documentation.)
F.tn_.titleVI.2012.docx