10.19.22 OUTBoard Packet - Laserfiche WebLink

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Demographic Request The following form was used to collect required data on Key Community Contacts and nonelected committee members. Orange County Transportation Service is required by Title VI of the Civil Rights Act of 1964 and related authorities to record demographic information on members of its boards and committees. Please provide the following information: Race/Ethnicity: National Origin:(if born outside the U.S.) ❑White ❑Mexican ❑Black/African American ❑Central American: ❑Asian ❑ South American: ❑American Indian/Alaskan Native ❑Puerto Rican ❑Native Hawaiian/Pacific Islander ❑Chinese ❑Hispanic/Latino ❑Vietnamese ❑Other(please specify): ❑Korean ❑Other(please specify): Gender: Age. ❑Male ❑Female ❑Less than 18 ❑45-64 El18-29 ❑65 and older Disability: El Yes El No ❑30-44 I choose not to provide any of the information requested above: ❑ Completed forms will remain on file as part of the public record. For more information regarding Title VI or this request, please contact the Orange County Transportation Services at 600 NC 86, Hillsborough, NC 27278 or (919)245-2002, email ntrivedi@orangecountync.gov: Please sign below acknowledging that you have completed this form. Thank you for your participation! Name (print): Signature: Implementation • Forms will be completed prior to NCDOT Title VI reviews and remain on file for three years. • All new and existing members of appointed decision-making boards or committees will be required to complete this form for reporting purposes. • If a member,for whatever reason,selects "1 choose not to provide any of the information requested above,"this will be accepted as a completed form. • If a member chooses not to provide any of the information on the form,the Title VI Coordinator will be permitted to indicate that member's race and gender, based on the Coordinator's best guess. • Data from these forms will be used to complete the Demographic Request Table. • Once a new member submits this form, the Demographic Request Table for the associated committee will be updated.