San Francisco Bay Area s1

Caltrans Public Participation Survey

The following information is being collected by the California Department of Transportation (Caltrans) in order to comply with Title VI of the Civil Rights Act of 1964, Nondiscrimination in Federally Assisted Programs. Please take a few moments to complete the following questions. The data you provide will enable Caltrans to identify residents and communities impacted by federally funded projects/or activities. Please check the appropriate boxes with an “X” that best describes you and return the completed survey to the event coordinator. Submittal of this information is voluntary. Thank you.

Male Female

Ethnicity

Hispanic or Latino Not Hispanic or Latino

American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander Other:

Disability

Yes No

Under 40 Over 40

Income

$22,050 or Less Over $22,051

Language

What language is primarily spoken in your household?

1 of 2 Revised: 3/18/10 Categories and Definitions

The minimum categories for data on race and ethnicity for federal statistics, program administrative reporting, and civil rights compliance reporting are defined as follows: a. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. b. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. c. Black or African American. A person having origins in any of the black racial groups of Africa. d. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. e. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. f. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

2 of 2 Revised: 3/18/10