Question title

Project Number (if known):

Question title

County of City the Project is in:

Question title

What is your home zip code?

Question title

Gender:

Select a response

Question title

What Street do you live on?
Please provide the street only - no house numbers

Question title

Have a Disability:

Select a response

Question title

Total Household Income:

Select a response

Question title

Age:

Select a response

Question title

Race/Ethnicity

Select a response

Question title

National Origin: (if born outside the U.S.)

Click to view results

If you prefer to email or mail the form:

Download a copy of the form NCDOT Title VI Form

  • Download the fillable form, complete it and email it to [email protected]
  • Download the fillable form, complete it and Mail it to  Environmental Analysis Unit, 1598 Mail Service Center, Raleigh, NC 27699-1598. 

Question title

How did you hear about this meeting? (newspaper advertisement, radio, flyer, and/or mailing)

Notice of Nondiscrimination and Accessibility Rights

In accordance with Title VI of the Civil Rights Act of 1964 and other nondiscrimination authorities, the N.C. Department of Transportation will not exclude from participation in, deny the benefits of, or subject to discrimination any person, based on race, color, national origin, Limited English Proficiency, income-level, sex, age, or disability (or religion, where applicable), under any NCDOT-funded programs or activities.

If you feel you have been discriminated against by NCDOT or its business partners, you may file a complaint. For information on filing a complaint or NCDOT’s nondiscrimination obligations, please contact:

NCDOT Office of Civil Rights

Title VI Nondiscrimination Program

1511 Mail Service Center

Raleigh, NC 27699

919-508-1808 or 800-522-0453

You may also visit:    https://www.ncdot.gov/programs/titleVI/

 

Anyone with a hearing or speech impairment may contact Relay NC by dialing 711 or 1-877-735-8200.

ATTENTION:

If you speak a language other than English, qualified interpreters or information written in other languages are available, free of charge, by calling 1-800-481-6494.

For more information regarding Title VI or this request, please contact the NCDOT Title VI Nondiscrimination Program at
(919) 508-1808 or toll free at 1-800-522-0453, or by email at
[email protected].  Thank you for your participation!