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Voluntary Title VI Public Involvement <br />Title V1 of the Civil Right's Act of 1954 requires North Carolina Department of <br />Transportation to gather statistical data on participants and beneficiaries of the agency's <br />federal -aid highway programs and activities. The North Carolina Department of <br />Transportation collects information on race, color, national origin and gender of the <br />attendees to this public meeting to ensure the inclusion of all segments of the population <br />affected by a proposed project. <br />The North Carolina Department of Transportation wishes to clarify that this information <br />gathering process is completely voluntary and that you are not required to disclose the <br />statistical data requested in order to participate in this meeting. This form is a public <br />document. <br />The completed forms will be held on file at the North Carolina Department of <br />Transportation. For Further information regarding this process please contact Sharon <br />Lipscomb, the Title VI Manager at telephone number 919.508.1808 or email at <br />slipscomb@ncdot.gov. <br />Project Name: Date: <br />Meeting Location: <br />Name (please print) <br />Gender: <br />❑ Male ❑ Female <br />General ethnic identification categories (check one) <br />❑ <br />Caucasian <br />❑ <br />Hispanic American <br />❑ American Indian/Alaskan Native <br />❑ <br />African Amcrican <br />❑ <br />Asian/Pacific Islander <br />Other: <br />Color: <br />National Origin: <br />After you complete this form, please fold it and place it inside the designated box on the <br />registration table. <br />Thank you for your cooperation. <br />