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DocuSign Envelope ID:3FDDF183-DEOC-45F5-AE17-OB9CF99E613F <br /> Gender: Age. <br /> ❑Male ❑Female <br /> ❑Less than 18 ❑45-64 <br /> ❑ 18-29 ❑65 and older <br /> Disability: ❑Yes ❑No <br /> ❑30-44 <br /> I choose not to provide any of the information requested above: ❑ <br /> Completed forms will remain on file as part of the public record. For more information regarding Title VI or this <br /> request, please contact the Orange County Public Transportation at 919-245-2008 or by email at <br /> octransportationservices@orangecountync.gov. <br /> Please sign below acknowledging that you have completed this form. <br /> Thank you for your participation! <br /> Name(print): <br /> Signature: <br /> Implementation <br /> • Forms will be completed prior to NCDOT Title VI reviews and remain on file for three years. <br /> • All new and existing members of appointed decision-making boards or committees will be required <br /> to complete this form for reporting purposes. <br /> • If a member, for whatever reason, selects `Y choose not to provide any of the information requested <br /> above,"this will be accepted as a completed form. <br /> • If a member chooses not to provide any of the information on the form, the Title VI Coordinator will <br /> be permitted to indicate that member's race and gender, based on the Coordinator's best guess. <br /> • Data from these forms will be used to complete the Demographic Request Table. <br /> • Once a new member submits this form, the Demographic Request Table for the associated <br /> committee will be updated. <br /> 8.2 KEY COMMUNITY CONTACTS <br /> Contact Name Community Name Interest or Affiliation Also a Committee <br /> Member? YIN <br /> Shannan Barnes Orange County Family Success Alliance N <br /> Marlyn Valeiko Orange County LEP Specialist/Outreach N <br /> Contact information for key community contacts is not public information and is maintained outside of this <br /> document. Any staff member who wishes to contact any individual listed above must request that <br /> information from the Title VI Coordinator. <br /> 8.3 5UMMARY OF OUTREACH EFFORTS MADE SINCE THE LAST TITLE VI PROGRAM SUBMISSION <br /> The following format is used to document URTS outreach efforts in reports to NCDOT. All meetings and <br /> disseminations of information capture information for the table below: <br /> Meeting Date Meeting Time Meeting Purpose Target Audience Information Disseminated <br /> 9/19/2020 11am Transit Services in General Public Brochures, Bus Rider 101, Bike on Bus <br /> Orange County Information <br />