WA ST Department of Transportation 4/11/2019

Title VIPlan-City of Everett VI Specialist for the City's [insert applicable department] Department." C.Where and when it is appropriate,Title VI Specialists will attempt to gather statistical data on the participants and beneficiaries of the departments' various programs and activities. Forms to the following effect will be made available at the public meetings, hearings, open houses, programs, classes, etc.officially conducted by the City's departments: 'Title VI Public Involvement "Title VI of the Civil Rights Act of 1964 requires the City of Everett (the City) to gather statistical data on the participants and beneficiaries of the City's programs and activities. The City collects information on race, color, national origin, and gender of the attendees of City-sponsored functions and activities to promote the inclusion of all segments of the City's population. "Your provision of the following information is completely voluntary. You are not required to provide this information in order to participate in this [meeting,hearing, open house, class,etc.]. The Title VI information gathered at this function will be handled as confidentially as possible. For further information, please call the City's Title VI Specialist representing this event, [insert name], at [insert phone number, or email the Specialist at [insert email address]. 'Please respond to the following questions: Project or Activity Title: Date: Meeting/Activity Location: Name (please print): Gender: D Male D Female General Ethnic Identification Category (please check one): D Caucasian D Hispanic American D American Indian/Alaskan Native D African American D Asian/Pacific Islander D Other Color: National Origin: "After completing this form,please fold it and place it [describe where the form should be deposited]. "Thank you for your cooperation!" 13