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14' <br /> i <br /> i <br /> Voluntary Title VI Public Involvement <br /> r <br /> c <br /> Title VI of the Civil Rights Act of 1964 requires the North Carolina Department of Transportation (NC <br /> DOT) to gather statistical data regarding participants and beneficiaries of the agency ' s federal- aid <br /> programs and activities . NC DOT 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 impacted by a <br /> proposed project . <br /> i <br /> NC DOT wishes to clarify that this information gathering process is completely voluntary and that you <br /> are not required to disclose the statistical data requested to participate in this meeting . This form is a <br /> public document used to collect data, only . <br /> E <br /> The completed forms will be held on file at the North Carolina Department of Transportation . For Further <br /> information regarding this process please contact the NCDOT Title VI Program at telephone number <br /> 919 . 508 . 1808 or email at titlevi ,.ncdot . gov . <br /> Project Name : Date . <br /> Meeting Location : <br /> Name (please print) Gender : <br /> ❑ Male ❑ Female <br /> General ethnic identification categories (check one) <br /> ❑ Caucasian ❑ Hispanic American ❑ American Indian/Alaskan Native <br /> ❑ African American ❑ Asian/Pacific Islander Other : <br /> Color : National Origin . <br /> After completing this form, please fold and place it inside the designated box on the registration table . <br /> Thank you for your cooperation . <br />