Tennessee Tech University Title VI
Survey of Sub-Recipients of Federal Funds
1
. Date of Survey _____________________________________________
2. Type of Survey _____________________________________________
3.
N
ame of Sub-Recipient ______________________________________
4.
N
ame of President/Director/CEO ______________________________
5
.
Name of Title VI Coordinator _________________________________
6.
N
on-Discrimination Policies: Does your institution/company have a written policy stating that
services will be provided to all persons without regard to race, color, or national origin?
_____ Yes _____ No
7.
P
osters: Are posters containing Title VI information prominently displayed within all of your
facilities?
_____ Yes _____ No
8. Do these posters include the name of the Title VI Coordinator to whom complaints should be
referred?
_____ Yes _____ No
9
.
Records: Are permanent records kept of all Title VI complaints?
_____ Yes _____ No
10. Complaints: If applicable, describe below any complaints received in this reporting period. I
f
needed, please attach a separate page. Include Name of Complainant, Race, Charge, and Findings.
Complaints:
11. Dissemination: Is Title VI information disseminated to your employees, applicants, students and
other beneficiaries of services?
_____ Yes _____ No
If yes, describe how all beneficiaries are informed:
________________________________________________________________________________
12. Are you confident that all beneficiaries are clearly aware of their rights under Title VI, including the
right to file a complaint?
_____ Yes _____ No
13. Are new employees clearly informed about their specific responsibilities to recipients of services
under Title VI?
_____ Yes _____ No
14. Are staff members periodically re-oriented or refreshed on information detailing their Title VI
responsibilities?
_____ Yes _____ No
If yes, state by whom and how:
__________________________________________________________________________________
15. Do staff members receive annual Title VI training?
_____ Yes _____ No
16. Compliance Assurance: Do all contracts to provide services contain a Title VI statement of
compliance? If yes, attach a copy of Title VI statement included in such contracts, FOR Pre award
Survey Only.
_____ Yes _____ No
17. Courtesy Titles: Does a written policy exist which states that courtesy titles (i.e., Mr., Mrs., Ms.,
Miss) will be used by staff to address beneficiaries without regard to race, color, or national origin
in all communications?
_____ Yes _____ No
18. Are all physical areas (exits, waiting rooms, dining areas, restrooms, etc.) provided and used without
regard to race, color, or national origin of beneficiaries?
_____ Yes _____ No
19. Do you have policies and service contract for identifying and assessing language needs of LEP
beneficiaries? If yes, please attach the policy and documented procedures, FOR Pre Award Survey
Only
_____ Yes _____ No
20. Within the last year, did you provide language assistance options or translate written material for
LEP individuals? If yes, please provide the total number of the following types of language services:
_____ Yes _____ No Total No. Individuals assisted _____________
Declarations
Respondent I declare that I have reviewed and approve the information provided in this self-survey
and to the best of my knowledge and belief, it is true, correct, and complete
Name/Title: ______________________________________________ Date: ____________________
Signature: _________________________________________________________________________
Administrative Head I declare that I have reviewed and approved the information provided in this self-
survey and to the best of my knowledge and belief, it is true, correct, and complete
Name/Title: _____________________________________________ Date: ______________________
Signature: __________________________________________________________________________
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