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DocuSign Envelope ID:3FDDF183-DEOC-45F5-AE17-OB9CF99E613F <br /> Appendix C <br /> NCDOT's Compliance Review Checklist for Transit <br /> I. Program Administration(General Requirements) <br /> Requirement.FTA C 47021B—Title VI Requirements and Guidelines for FTA Recipients,Chapter III—General Requirements and Guidelines. <br /> Note: Every NCDOT subrecipient receiving any of the FTA Formula Grants listed above must complete this section. <br /> Requested Items <br /> (Please attach electronic documents(.pdf,.doe,etc.)or provide links to online versions) Completed <br /> 1. A copy of the recipient's signed NCDOT's Title VI Nondiscrimination Agreement ❑ <br /> 2. Title VI Policy Statement(signed) ❑ <br /> 3. Title VI Notice to the Public,including a list of locations where the notice is posted ❑ <br /> 4. Type the name and title of your Title VI Coordinator and attach a list of their Title VI duties ❑ <br /> Name/Title: <br /> 5. Title VI Complaint Procedures(i.e.,instructions to the public regarding how to file a Title VI ❑ <br /> discrimination complaint) <br /> 6. Title VI Complaint Form ❑ <br /> 7. List of transit-related Title VI investigations,complaints, and lawsuits(i.e., discrimination ❑ <br /> complaints log) <br /> 8. Public Participation Plan, including information about outreach methods to engage traditionally <br /> underserved constituencies(e.g.,minorities, limited English proficient populations(LEP),low- ❑ <br /> income, disabled),as well as a summary of outreach efforts made since the last Title VI Program <br /> submission <br /> 9. Language Assistance Plan for providing language assistance to persons with limited English <br /> proficiency(LEP),based on the DOT LEP Guidance,which requires conducting four-factor ❑ <br /> analyses <br /> 10. A table depicting the membership of non-elected committees and councils,the membership of <br /> which is selected by the recipient,broken down by race,and a description of the process the ❑ <br /> agency uses to encourage the participation of minorities on such committees <br /> 11. A copy of board meeting minutes,resolution, or other appropriate documentation showing the <br /> board of directors or appropriate governing entity or official(s)responsible for policy decisions ❑ <br /> reviewed and approved the Title VI Program <br /> 12. A description of the procedures the agency uses to ensure nondiscriminatory administration of ❑ <br /> programs and services <br /> 13. If you pass through FTA funds to other organizations, include a description of how you <br /> monitor your subrecipients for compliance with Title VI,and a schedule for your subrecipients' ❑ <br /> Title VI Program submissions. <br /> ➢ No Subrecipients ❑ <br /> 14. A Title VI equity analysis if you have constructed or conducted planning for a facility, such <br /> as a vehicle storage facility,maintenance facility, operation center, etc. ❑ <br /> ➢ No Facilities Planned or Constructed❑ <br /> 15. Copies of environmental justice assessments conducted for any construction projects during <br /> the past three years and, if needed based on the results, a description of the program or other <br /> measures used or planned to mitigate any identified adverse impact on the minority or low- ❑ <br /> income communities <br /> ➢ No Construction Projects❑ <br />