[AGENCY]

Title VI Program

This practical tool provides a framework to guide you through organizing your Title VI Program into one document for reporting purposes. Within this tool, sample table of contents and forms are provided. These are intended as guides and may not be complete for the purposes of all agencies. .

[AGENCY]’s TITLE VI PROGRAM

Developed:

Approved by [AGENCY]’s Board of Directors:

SAMPLE INTRODUCTORY LANGUAGE:

This document was prepared by [AGENCY] and approved by its Board of Directors (or appropriate governing entity) to comply with Title VI of the Civil Rights Act of 1964, including new provisions detailed in U.S. Department of Transportation’sFTA Circular 4702.1B, “Title VI Requirement and Guidelines for Federal Transit Administration Recipients.”

SAMPLE Table of Contents*

Title VI Notice to the Public
List of Locations Where Title VI Notice Is Posted
Title VI Complaint Procedures
Title VI Complaint Form
List of Transit-Related Title VI Investigations, Complaints, and Lawsuits
Public Participation Plan
Summary of Outreach Efforts
Language Assistance Plan
Table Depicting the Membership of Non-Elected Committees And Councils
Description of Subrecipient Monitoring and Schedule of Subrecipient Title VI Program Submissions
Title VI Equity Analysis
Additional Information for Transit Providers that operate less than 50 fixed route vehicles in peak service and are not located in an Urbanized Area (UZA) of 200,000: System-Wide Policies and Service Standards
Effective Practices to Fulfill the Service Standard Requirement
Effective Practices to Fulfill the Service Policy Requirement
Board of Directors Approval of [Agency]’s Title VI Program
Appendices

* Caltrans DMT has developed a fillable PDF Title VI Program Checklist that should be consulted when organizing your Title VI Program. This checklist must be included with plans that are submitted to Caltrans and is available at

[AGNECY]’s Title VI Notice to the Public

List of Locations Where Title VI Notice Is Posted

[AGENCY]’s Title VI notice to the public is currently posted at thefollowing locations:

Location Name / Address / City

The Title VI notice and program information is also provided on [AGENCY]’s website at:

www.

Title VI Complaint Procedures

[AGENCY] Title VI Complaint Form

SAMPLE COMPLAINT FORM

Section I: Please write legibly
1.Name:
2. Address:
3. Telephone: / 3.a. Secondary Phone(Optional):
4. Email Address:
5. Accessible Format Requirements? / [ ] Large Print / [ ] Audio Tape
[ ] TDD / [ ] Other
Section II:
6. Are your filing this complaint on your own behalf? / YES* / NO
*If you answered “yes” to #6, go to Section III.
7. If you answered “no” to #6, what is the name of the person for whom you are filing this complaint? Name:
8. What is your relationship with this individual:
9. Please explain why you have filed for a third party:
10. Please confirm that you have obtained permission of the aggrieved party to file on their behalf. / YES / NO
Section III:
11. I believe the discrimination I experienced was based on (check all that apply):
[ ] Race [ ] Color [ ] National Origin
12. Date of alleged discrimination: (mm/dd/yyyyy)
13. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known), as well as names and contact information of any witnesses. If more space is needed, please use the back of this form.

[AGENCY] Title VI Complaint Form, Page 2

SAMPLE COMPLAINT FORM

Section IV:
14. Have you previously filed a Title VI complaint with [AGENCY]? / YES / NO
Section V:
15. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
[ ] YES* [ ] NO
If yes, check all that apply:
[ ] Federal Agency ______[ ] State Agency ______
[ ] Federal Court ______[ ] Local Agency ______
[ ] State Court ______
16. If you answered “yes” to #15, provide information about a contact person at the agency/court where the complaint was filed.
Name:
Title:
Agency:
Address:
Telephone: Email:
Section VI:
Name of Transit Agency complaint is against:
Contact Person:
Telephone:

You may attach any written materials or other information that you think is relevant to your complaint.

Signature and date are required below to complete form:

Signature______Date______

Please submit this form in person or mail this form to the address below:

List of Transit-Related Title VI Investigations, Complaints, and Lawsuits

Sample Table from Appendix E of FTA C 4702.1B

Type of Process / Date / Summary (including basis of complaint) / Status / Action(s) Taken
Investigations
1.
2.
Lawsuits
1.
2.
Complaints
1.
2.

Public Participation Plan

Sample Table of Contents

[FTA C 4702.1B, Chapter III-5, #8]

1. Introduction

1.1. Purposes of This Plan

1.2. Demographic Analysis of the Population

2. Public Participation Process

2.1. Approach to Public Participation

2.2. Outreach Requirements and Activities

2.2.1. Strategies to engage Minority and LEP Populations in the Public Participation Process

Summary of Outreach Efforts Made Since Last Title VI Submission

Sample Categories to include in the summary of your agency’s outreach:

  • Reoccurring outreach locations
  • How frequently outreach activities take place
  • Annual Ad hoc outreach
  • Unmet needs processes
  • Outreach for Coordinated Plan Updates

Language Assistance Plan

Table Depicting the Membership of Non-Elected Committees and Councils

Sample Table from Appendix F of FTA C 4702.1B

Committee / Body / African American / Asian American / Caucasian / Latino / Native American / Other
Citizens Advisory Council / 20% / 10% / 40% / 25% / 5%

Description of Subrecipient Monitoring and Schedule of Subrecipient Title VI Program Submissions

Title VI Equity Analysis

Additional Information for Transit Providers that operate less than 50 fixed route vehicles in peak service and are not located in an Urbanized Area (UZA) of 200,000: System-Wide Policies and Service Standards

Effective Practices to Fulfill the Service Standard Requirement

Vehicle Load Standards

Vehicle Headway Standards

On-Time Performance Standards

Service Availability Standards

Effective Practices to Fulfill the Service Policy Requirement

Vehicle Assignment Policy

Transit Amenities Policy

Board of Directors Approval of [AGENCY]’s Title VI Program

Appendices

Updated: 11/3/2018

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