Project Number (if known):
County or City the Project is in:
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Gender:
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What Street do you live on?
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Have a Disability:
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Race/Ethnicity: Select all that apply
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Total Household Income:
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Age:
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If you selected American Indian or Alaska Native above:
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If you selected Asian above, provide details below.
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If you selected Black or African American above, provide details below.
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If you selected Hispanic or Latino above, provide details below.
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If you selected Middle Eastern or North African above, provide details below.
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If you selected Native Hawaiian or Pacific Islander above, provide details below.
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If you entered White above, provide details below.
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If you prefer to email or mail the form:

Download a copy of the form NCDOT Title VI Form 

Formulario de Participación Pública / Título VI

  • Download the fillable form, complete it and email it to NCDOT-TitleVI@publicinput.com
  • Download the fillable form, complete it and Mail it to  Environmental Analysis Unit, 1598 Mail Service Center, Raleigh, NC 27699-1598. 
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

984-236-1200

You may also visit:    https://www.ncdot.gov/initiatives-policies/access-for-all/nondiscrimination-program/Pages/default.aspx

 

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
(984) 236-1200, or by email at titleVI@ncdot.gov.  Thank you for your participation!

Revised 2024