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Appendix E <br />Vohuttaty Title VI Public Ltvolvement <br />Title VI of the Civif Right's Act of 1964 requires North Carolina Deparhnent of Transportation to gather <br />statistical data on participants and beneficiaries of the agency's federal-aid highway programs and <br />activities. The North Carolina Department of Transpor[atiou collects information on race, color, national <br />origin and gender of the attemdees to this public meeting to ensure the inclusion of all segments of the <br />population affected by a proposed project. <br />The North Carolina Deparhnent of Transportation wishes to clarify that this information gathering process <br />is completely voluntmy and that you are not required to disclose the statistical data requested in order to <br />participate in this meeting. This form is a public document. <br />'f he completed forms will be held ou file at the North Carolina Deparhnent of Transportation. Por Farther <br />information regarding this process please contact Sharon Lipscomb, the Title VI Manager, by phone at <br />(919) $08-1830 or email at slipscomb~dotstnte.naus. <br />Project Name: Date: <br />i\~teeting Location: <br />Name (please print) Gender: <br />^ Male ^ Female <br />General ethnic identification Cate ones check one): <br />^ Caucasian His mric American ^ American Indiat>/Alaskan Native <br />^ African American ^ AsiatrlPacific Islander Other: <br />Color: National Origin: <br />ARer you complete this form, please fold it and place it inside the designated box on the registration table. <br />Thanks you for your cooperation! <br />is <br />