Form SFN60149 "Nddot Title VI Public Participation Survey" - North Dakota

What Is Form SFN60149?

This is a legal form that was released by the North Dakota Department of Transportation - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • The latest edition provided by the North Dakota Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN60149 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Transportation.

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Download Form SFN60149 "Nddot Title VI Public Participation Survey" - North Dakota

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NDDOT TITLE VI PUBLIC PARTICIPATION SURVEY
North Dakota Department of Transportation, Civil Rights
SFN 60149 (Rev. 12-2014)
PLEASE USE DARK INK AND PRINT CLEARLY
The Civil Rights Act of 1964 and related nondiscrimination authorities require the North Dakota
Department of Transportation to ensure everyone has the opportunity to comment on the transportation
programs and activities that may affect their community.
To help with that, we ask that you respond to the following questions. You are not required to disclose
the information requested in order to participate. Any information provided to the NDDOT will be
retained solely for the purpose of collecting statistical data to ensure inclusion of all segments of the
population affected by transportation programs and activities.
Female
Male
Yes
No
Disability:
Sex:
Age:
34 and younger
35-54
55 and older
Race:
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Asian
White
Other
Black/African American
Hispanic or Latino
Language most frequently spoken in your home:
Arabic
German
Somali
Vietnamese
Bosnian
Nepali
Spanish
Other
Croatian
Russian
Swahili
English
Serbian
Turkish
Do you receive public assistance?
Yes
No
Indicate how you heard about the event:
Internet
Mailing
NDDOT Contact
Newspaper
Radio
Social Service Agency
Television
Advocacy Group (which group)
Other
For Office Use
MPO
Event Date
Event Date
City
County
Bismarck-Mandan
/
/
Fargo-Moorhead Metro COG
Grand Forks-East Grand Forks
Subrecipient
ROW
Div/Dist Number
PCN
Consultant
Negotiation
Yes
Relocation
No
After you have completed this form, please place it in the designated location.
NDDOT TITLE VI PUBLIC PARTICIPATION SURVEY
North Dakota Department of Transportation, Civil Rights
SFN 60149 (Rev. 12-2014)
PLEASE USE DARK INK AND PRINT CLEARLY
The Civil Rights Act of 1964 and related nondiscrimination authorities require the North Dakota
Department of Transportation to ensure everyone has the opportunity to comment on the transportation
programs and activities that may affect their community.
To help with that, we ask that you respond to the following questions. You are not required to disclose
the information requested in order to participate. Any information provided to the NDDOT will be
retained solely for the purpose of collecting statistical data to ensure inclusion of all segments of the
population affected by transportation programs and activities.
Female
Male
Yes
No
Disability:
Sex:
Age:
34 and younger
35-54
55 and older
Race:
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Asian
White
Other
Black/African American
Hispanic or Latino
Language most frequently spoken in your home:
Arabic
German
Somali
Vietnamese
Bosnian
Nepali
Spanish
Other
Croatian
Russian
Swahili
English
Serbian
Turkish
Do you receive public assistance?
Yes
No
Indicate how you heard about the event:
Internet
Mailing
NDDOT Contact
Newspaper
Radio
Social Service Agency
Television
Advocacy Group (which group)
Other
For Office Use
MPO
Event Date
Event Date
City
County
Bismarck-Mandan
/
/
Fargo-Moorhead Metro COG
Grand Forks-East Grand Forks
Subrecipient
ROW
Div/Dist Number
PCN
Consultant
Negotiation
Yes
Relocation
No
After you have completed this form, please place it in the designated location.