The following information is being collected by the California Department of Transportation (Caltrans) in order to comply with Title VI of the Civil Rights Act of 1964, Nondiscrimination in Federally Assisted Programs. Please take a few moments to complete the following questions. The data that you provide will enable Caltrans to identify impacted residents and communities affected by the Federal-Aid Highway Program. Please check the appropriate boxes which best describe you. Submittal of this information is voluntary.

1.What is your gender?

Male

Female

Other

2.What is your age?

Under 40

Over 40

3.What is you ethnicity?

Hispanic or Latino

Not Hispanic or Latino

4.Do you have a disability?

Yes

No

5.What is your race?

American Indian/Alaskan Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian

White

Other

6.What language is primarily spoken in your household?

7.What is your household income?

$24,858 or less

Over $24,858