Administrative Office of the Courts
Title VI Post Award Survey

-This survey must be completed annually by each facility or agency subrecipient or contractor obtaining grant assistance from the Administrative Office of the Courts.
-The survey must be completed at one sitting. If you exit the survey while partially complete all information provided will be deleted. You may review or print the survey prior to completing it so that required information can be assembled.
-Questions that begin with an asterisk (*) are required.
-The completed document must be submitted electronically by clicking DONE at the end of the survey.

Question Title

* 1. Administrative Information

Date of Survey:

Name of Agency/Facility:

Name of the Agency/Facility Head and Title:

Name of the Agency/Facility Compliance Designee for Title VI:

Name of the Grant(s) Received from the Administrative Office of the Courts:

Question Title

* 2. What is the racial composition of your agency employees? **A definition of each race is at the end of the survey.

Hispanic or Latino

White (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

American Indian or Alaska Native (not Hispanic or Latino)

Two or More Races (not Hispanic or Latino)

TOTAL EMPLOYEES

Question Title

* 3. Does your agency/facility have a Governing Board or Advisory Group? (If yes answer questions 4, 5, and 6, if no skip to question 7.)

Yes

Question Title

* 4. How is the Governing Board or Advisory Group appointed?

By staff

By general membership

By agency/facility owner

By agency head or facility administrator

Appointed by action of the Supreme Court, State Legislature, County Commission, Municipal Council or other elected body

As required by grantor agency

Question Title

* 5. What is the racial composition of the Governing Board or Advisory Group? **A definition of each race is at the end of the survey.

Hispanic or Latino

White (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

American Indian or Alaska Native (not Hispanic or Latino)

Two or More Races (not Hispanic or Latino)

TOTAL MEMBERS

Question Title

* 6. What steps are taken to obtain minority representation on the Governing Board or Advisory Group? (Answer required if in your geographic service area, minorities represent 5% of the population or more)

Question Title

* 7. Policies and Contracts

	Yes	No
Does your agency/facility have a written policy stating that services will be provided to all persons without regard to race, color, or national origin?	Does your agency/facility have a written policy stating that services will be provided to all persons without regard to race, color, or national origin? Yes	Does your agency/facility have a written policy stating that services will be provided to all persons without regard to race, color, or national origin? No
Does your agency/facility have a written policy and procedures regarding the provision of Limited English Proficiency for clients who have limited or no English skills?	Does your agency/facility have a written policy and procedures regarding the provision of Limited English Proficiency for clients who have limited or no English skills? Yes	Does your agency/facility have a written policy and procedures regarding the provision of Limited English Proficiency for clients who have limited or no English skills? No
Does your agency/facility have written procedures for hearing and reviewing Title VI complaints?	Does your agency/facility have written procedures for hearing and reviewing Title VI complaints? Yes	Does your agency/facility have written procedures for hearing and reviewing Title VI complaints? No
Does your agency/facility subcontract for the provision of direct services to clients/customers?	Does your agency/facility subcontract for the provision of direct services to clients/customers? Yes	Does your agency/facility subcontract for the provision of direct services to clients/customers? No
If yes, do the contracts contain a statement of compliance with Title VI by the subcontractor?	If yes, do the contracts contain a statement of compliance with Title VI by the subcontractor? Yes	If yes, do the contracts contain a statement of compliance with Title VI by the subcontractor? No
Are you familiar with Title IX of the Education Amendments of 1972?	Are you familiar with Title IX of the Education Amendments of 1972? Yes	Are you familiar with Title IX of the Education Amendments of 1972? No

Question Title

* 8. Has the Agency/Facility Compliance Designee for Title VI received training on the agencies requirements under Title VI?

Yes

Question Title

* 9. Title VI Training

Total number of staff:

Provide the actual number and percentage of staff trained in Title VI:

Describe method used to train staff and the method used to verify and record members of staff completing training:

List dates Title VI training was offered to staff:

Question Title

* 10. Who are the beneficiaries/recipients of the services you provide through the grant funding received from the Administrative Office of the Courts?

Other Agencies

Families

Children/teens

Community

Indigent Defendents

Employees

Other (please specify)

Question Title

* 11. Minority representation of recipients/beneficiaries of services provided by this grant. What is the racial composition of the recipients/beneficiaries served by this grant? **A definition of each race is at the end of the survey.

Hispanic or Latino

White (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

Asian (Not Hispanic or Latino)

American Indian or Alaska Native (not Hispanic or Latino)

Two or More Races (not Hispanic or Latino)

TOTAL NUMBER OF RECIPIENTS/BENEFICIARIES

Question Title

* 12. List the services you provide with the grant funding received from the Administrative Office of the Courts?

Question Title

* 13. DECLARATION OF RESPONDENT: I declare that I have reviewed and approved the information provided in this survey and to the best of my knowledge believe it to be accurate and truthful.

Signature (by typing your name here you are certifying your responses):

Date:

Position of Individual Completing Survey:

** Definitions of Race & Ethnicity Categories

Race and ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. Definitions of the race and ethnicity categories are as follows:

-Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

-White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

-Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

-Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

-Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

-American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

-Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

100% of survey complete.