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Subrecipient Risk Assessment Title VI RE 1 Subrecipient Risk Assessment Title VI

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Tennessee Tech University: Title VI
Survey of Subrecipients of Federal Funds
Date of Survey:
Name of Institution/School:
Name of President/Director:
Type of Survey
Name of Local Title VI Coordinator (Affirmative Action Officer):
Initial
Annual
Other
RESPONSES
AFFIRMATIONS
Yes
No
1. Does your institution/school have a written policy stating that
services will be provided to all persons without regard to race,
color, or national origin?
Nondiscrimination
Yes
No
2. Are posters containing Title VI information prominently displayed
within the facility?
Posters
Yes
No
Do these posters include the name of the Local Coordinator to whom
complaints should be referred?
Yes
No
3. Are permanent records kept of all Title VI complaints?
Records
Yes
No
4. Is Title VI information disseminated to your employees, applicants,
students and other beneficiaries of services?
Dissemination
If yes, describe how all beneficiaries are informed.
Yes No
5. Are you confident that all beneficiaries are clearly aware of their
rights under Title VI, including the right to file a complaint?
If applicable, describe below any complaints received in this
reporting period.
Rights and
Complaints
Complainant
___________
___________
___________
Race
___________
___________
___________
Charge Findings
RESPONSES
AFFIRMATIONS (cont.)
Yes
No
6. Are you confident that all beneficiaries are clearly aware of their
rights under Title VI, including the right to file a complaint?
Beneficiaries
Yes
No
7. Are new employees clearly informed about their specific
responsibilities to recipients of services under Title VI?
New Employees
Yes
No
8. Are staff members periodically re-oriented or refreshed on
information detailing their Title VI responsibilities?
If yes, state by whom and how.
Staff Members
Yes
No
9. 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 INITIAL SURVEY ONLY.
Compliance
Assurance
Yes
No
10. Does a written policy exist that 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?
Courtesy Titles
Yes
No
11. Are all physical areas (exist, waiting rooms, dining areas, restrooms,
etc.) provided and used without regard to race, color, or national
origin of beneficiaries?
Physical Areas
RESPONSES
AFFIRMATIONS (cont.)
Yes
No
12. Is there a particular Title VI area in which you would like
assistance?
If yes, please describe.
Assistance
COMMENTS
State any particular problems
you find with the manual,
self-survey, etc.
DECLARATION OF RESPONDENT:
I declare that I have completed the data in this survey and to the best of my knowledge and belief, it is true, correct, and complete.
________________________________________________________
Signature/Position of Individual Completing Survey
DECLARATION OF 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.
________________________________________________________
Signature of Administrative Head
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Subrecipient Risk Assessment Title VI RE 1 Subrecipient Risk Assessment Title VI

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Completed 14 March 2020

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