NonDiscrimination in Federal Financial Assistance Programs

General Services Administration Form Approved

Nondiscrimination in Federal Financial Assistance Programs OMB No.: 3090-0228

Compliance Questionnaire for Recipients Exp. Date : 06/30/2006

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions searching existing date sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Civil Rights, General Services Administration, 1800 F Street, NW, Washington, DC 20405.

This compliance questionnaire is used in conjunction with the Federal Surplus Personal Property Donations Program. This program is a Federal financial assistance program administered by the General Services Administration (GSA), a Federal agency. As a recipient, your organization signed a nondiscrimination assurance statement agreeing to conduct your programs and activities in compliance with Federal nondiscrimination laws. Those laws are the following: Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments Act of 1972, as amended; Section 504 of the Rehabilitation Act of 1973, as amended; Age Discrimination Act of 1975; and Federal Property Management Act of 1949, as amended.

Generally, the aforementioned laws provide that no person in the United States shall, on the ground of race, color, national origin, sex, disability or age, be subject to discrimination under any program or activity receiving Federal financial assistance. Federal agencies that provide financial assistance are responsible for ensuring that recipients of Federal assistance operate their programs and activities in a nondiscriminatory manner. Thus, GSA’s implementing and enforcement regulations for these laws are located at 41 CFR 101-4 et. seq; 41 CFR 101-6.2 et. seq; 41 CFR 101-8.3 et. seq; and 41 CFR 101-8.7 et. seq. Pursuant to these laws and regulations, your organization must keep records and submit compliance reports to GSA for the purpose of determining your organization's compliance.

Your organization’s responses to this questionnaire will be used by the GSA’s Office of Civil Rights (OCR) to help determine if your organization is in compliance with these laws and regulations. In order to analyze this information, OCR personnel will have access to this information. OCR will retain this information for four (4) years from the time of receipt.

Organization Name: _______________________________________________

Street Address: _______________________________________________

City: _______________________________________________

State: _______________________________________________

Zip: _______________________________________________

Submitted by:

Name: _______________________________________________

Title: _________________________________________ _

Telephone: _______________________________________________

Fax: _______________________________________________

E-mail: _______________________________________________

Preparation Date: __________________________________________

I. Organizational Background:

A. Please describe the nature and purpose of your agency/organization, to include programs and activities conducted by your agency/organization.

B. Please mark one or more of the following categories that best describes the “organizational type” for your agency/organization:

 State Government Agency

 County or City Government Agency

 Non-profit Organization

 Healthcare-related provider

 Educational provider

 Provider to the Homeless or Impoverished

 Women-focused

 Program for Older Individuals

 Individuals with Disabilities-focused

 Other

If other, please explain:

II. Civil Rights Data:

[NOTE: For all questions regarding race or ethnicity reporting, first, report the race,( i.e., American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Other Pacific Islander, and White); then report ethnicity (i.e., Hispanic or Non-Hispanic].

A. For each of your agency/organization’s programs that received Federal surplus property, please provide the number of individuals, based on race, ethnicity and sex, that are eligible to participate in the program, using the charts below. If submitting responses hard-copy, simply make additional copies of the charts below for reporting the race, ethnicity and sex data for each federally assisted program.

Please report the number of individuals in each of the following racial/ethnic/sex categories:

Calendar Year

Race		Ethnicity
American Indian or Alaska Native		Hispanic or Latino
Asian		Non-Hispanic or Non-Latino
Black or African American		TOTAL
Native Hawaiian or Other Pacific Islander		Sex
White		Male
TOTAL		Female
		TOTAL

B. Individuals who, because of their national origin, are Limited English Proficient (LEP) are entitled to meaningful access to federally assisted programs and activities. (See GSA’s LEP guidance for recipients of Federal financial assistance at http://www.gsa.gov/civilrights.) Does your service areas' population include LEP individuals?

 Yes  No

C. If so, what are the languages most encountered?

 Spanish

 Chinese

 Vietnamese

 Korean

 Other

If, other please explain:

D. Where non-English languages are encountered, what type(s) of translation or interpretation assistance services does your agency/organization provide to LEP individuals? (Please mark all that apply)

 Bilingual Staff

 Contract Interpreter/Translator

 Translated Written Materials

 Volunteers

 Local community-based organization

 Local college/university language department

 State agency that provides this service

 Other

E. How does your agency/organization notify its LEP population regarding the availability of LEP assistance? Please describe all methods used.

• Posting a Written Notice in appropriate Non-English Language

• Brochure

• Other

If other, please explain:

F. Did your agency/organization incur any additional cost during the previous calendar year related to providing LEP assistance?

 Yes  No

G. If so, what were your agency/organization’s costs for the previous calendar year in providing LEP assistance? $_________

H. Section 504 of the Rehabilitation Act of 1973, as amended, provides that no qualified individuals with disabilities shall, on the basis of disability, be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination under any program or activity that receives or benefits from Federal assistance from GSA. (GSA’s implementing regulation for Section 504 is located at 41 CFR 101-8.302, et seq.)

(i) For each of the following areas listed below that is available for the public use, indicate whether your agency/organization’s facilities are accessible to individuals with disabilities:

Area Do You Have Do You Comply with Uniform

the Following? Accessibility Standards?

Telephone  Yes  No  Yes  No

Restrooms  Yes  No  Yes  No

Water Fountains  Yes  No  Yes  No

Hallways  Yes  No  Yes  No

Entrances/Exits  Yes  No  Yes  No

Lounges  Yes  No  Yes  No

Cafeteria  Yes  No  Yes  No

Elevators  Yes  No  Yes  No

Conference Rooms  Yes  No  Yes  No

Work/Study Areas  Yes  No  Yes  No

Classrooms  Yes  No  Yes  No

Parking  Yes  No  Yes  No

(ii) How does your agency/organization assist individuals that are hearing-impaired or deaf and to individuals who are visually impaired or blind? Please explain.

I. Title IX of the Education Amendments Act of 1972 provides that, except as where exempt under the law, no person shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education or training program conducted by a recipient of Federal financial assistance. Implementing regulations require that where recipients conduct or provide education or training programs, they must: (1) Designate a Title IX coordinator; (2) Establish a written policy with regard to Title IX and disseminate such policy--Title IX coordinator’s name and contact information should be included in such policy; and (3) Establish procedures to promptly and equitably resolve complaints that allege discrimination on the basis of sex in the agency/organization’s education programs or activities.

(i) Does your agency/organization offer any type of training or educational programs/activities?

(If answer is no, skip to III-A below—“Marketing/Advertisement”)

 Yes  No

(ii) If so, please describe type(s) of training/educational programs/activities, the target audience of such programs/activities, and recruitment/admission criteria/process:

(iii) Does your agency/organization have an administrative grievance procedure established should

an individual wish to file a sex-based complaint with regard to the way in which your agency/organization operates its educational or training programs/activities?

 Yes  No

III. Marketing/Advertisement of Programs/Activities:

A. Does your agency/organization market and/or advertise your

programs/activities/benefits/services?

 Yes  No

If No, skip to Section IV, Compliance Information

B. If yes, please use the following chart to provide the population profile for the targeted audience for the marketing/advertisement of your programs/activities. Example: If your targeted audience for marketing/advertising your program is county-wide, you may use the 2000 U.S. Census Data.

Calendar Year

Race	Number	Ethnicity	Number
American Indian or Alaska Native		Hispanic or Latino
Asian		Non-Hispanic or Non-Latino
Black or African American
Native Hawaiian or Other Pacific Islander		Sex	Number
White		Male
Total		Female
		Total

C. Please describe the way in which your agency/organization ensures that individuals who are eligible to participate in your federally assisted programs and activities are aware of and have a full and fair opportunity to participate.

IV. Complaint Information:

Individuals have the right to either (1) file an administrative complaint with GSA based on discrimination in federally assisted programs or activities (GSA only has jurisdiction over recipients of Federal surplus property); or (2) file a lawsuit in Federal court. Complainants may also have other avenues available also. With regard to the way in which your agency/organization operates/administers its federally assisted programs and/or provides services/benefits:

A. Have any complaints (oral or written, informal or formal), lawsuits, charges, inquiries, etc. been filed with any Federal, State or local agency, alleging that your agency/organization--or any component thereof—discriminated against an individual or individuals on the basis of race, color, national origin, sex, disability or age?

 Yes  No

B. If so, please provide the following for each complaint received or filed for the last two calendar years: Date of Complaint, Basis (i.e., race, national origin, etc.), Issue(s,) Status of Complaint

V. Information Regarding Your Participation in the Federal Surplus Property Program:

A. How did your agency/organization learn about the program?

 Word of Mouth

 Information Briefing/Presentation

 Television or radio

 Newspaper

 Mailing

 Internet

 Other

B. How does your agency/organization find out about the availability of the property?

C. Has your agency experienced problems in the past in obtaining the type of property your agency/organization needs? ____Yes ____No

D. How would you rate the quality of the property that your agency/organization has received through the Federal surplus property program?

 Excellent

 Good

 Fair

 Poor

VI. Unavailable Compliance Data:

Federal civil rights laws and regulations require recipients of Federal financial assistance to collect and maintain compliance data and, upon request, to provide such data--as requested by the Federal agency--for the purpose of determining compliance with applicable Federal civil rights laws and regulations.

A. Is your agency/organization unable to provide any of the information requested in this submission?

 Yes  No

B. If so, please identify the corresponding number and/or type of data that your agency/organization is unable to provide (as requested above) due to unavailability of such data.

C. Briefly describe your agency/organization’s plan(s) to begin collecting and maintaining such data for future requests regarding civil rights compliance. Your plan should provide dates and action(s) that will be taken to ensure such data is collected and maintained. The Office of Civil Rights is available to provide assistance in developing such a plan.

VII. Amount of Time to Submit this Questionnaire:

Please provide the estimated amount of time that your agency spent in completing this compliance submission. Number of hours: _______

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