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HomeMy WebLinkAbout- - Approval of Title VI Program Federal Tra - 4/17/2012CITY COUNCIL AGENDA REPORT MEETING DATE: APRIL 17, 2012 ITEM NUMBER: SUBJECT: APPROVAL OF THE TITLE VI PROGRAM FOR THE USE OF FEDERAL TRANSIT ADMINISTRATION FUNDING DATE: APRIL 5, 2012 FROM: PUBLIC SERVICES DEPARTMENT PRESENTATION BY: RAJA SETHURAMAN, ACTING DIRECTOR PUBLIC SERVICES DEPARTMENT FOR FURTHER INFORMATION CONTACT: FARIBA FAZELI, INTERIM CITY ENGINEER, 714-754-5335 RECOMMENDATION It is recommended that City Council approve the Title VI Plan (Attachment 1) as required by the Federal Transit Administration (FTA) guidelines for grant funding compliance purposes. BACKGROUND In 2010, the Public Services Department received a $500,000 grant for the construction of the Fairview Channel Multipurpose Trail Project. Funding was received from the FTA and is administered by OCTA. The project is located in the lower northern portion of Fairview Park and consists of a Y mile long, eight -foot wide colored concrete trail, four -foot wide decomposed granite trail, fencing, and signage. The City matched the grant funds with $321,000 of Park Development Funds for a total project cost of $821,000. The trail is currently under construction and is scheduled to be completed in August 2012. ANALYSIS Title VI of the Civil Rights Act of 1964 provides that "no person in the United Stated shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance". To fulfill this basic civil rights mandate, each federal agency that provides financial assistance for any program is authorized and directed by the United States Department of Justice to apply provisions of Title VI to each program by issuing general rules, regulations, or requirements. Since 1972, the FTA has required recipients and non -transit grant sub recipients of Federal assistance to certify compliance with the requirements of Title VI as part of the funding eligibility process. The Title VI Plan consists of the Self -Certification Document, Notification to the Public of Title VI Rights, Title VI Complaint Procedure & List of Current Title VI investigations, complaints or lawsuits, Public Involvement Plan, and Limited English Proficiency Plan. No other alternatives have been considered. Approval of the Title VI Plan is required by the FTA for the use of the grant funding for the Fairview Channel Multipurpose Trail. FISCAL REVIEW There is no fiscal review required for the approval of the Title VI Plan. LEGAL REVIEW The City Attorney's office has received the attached plan and has approved it as to form. CONCLUSION In 2010, the City received a FTA grant for construction of the Fairview Channel Multipurpose Trail. The FTA grant guideline requires the City to comply with the Title VI Plan. It is recommended that the City Council approve the City's Title VI Plan, and direct staff to submit the plan and a copy of the Council meeting minutes to OCTA's Office of Civil Rights. Acceptance by OCTA will allow the City to close-out the project upon completion and receive the final grant reimbursement. RAJA SETHURAMAN, Acting Director Public Services Department Attachments: Distribution: 11 1" Title VI Plan IBA FAZELI Interim City Engineer Chief Executive Officer Acting Deputy City Clerk Staff 2 INTRODUCTION Title VI of the Civil Rights Act of 1964 provides that "no person in the United Stated shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." To fulfill this basic civil rights mandate, each federal agency that provides financial assistance for any program is authorized and directed by the United States Department of Justice to apply provisions of Title VI to each program by issuing general rules, regulations, or requirements. Since 1972, the Federal Transit Administration (FTA) has required recipients of Federal assistance to certify compliance with the requirements of Title VI as part of the funding eligibility process. SUB -RECIPIENTS Title 49 Code of Federal Regulation (CFR) section 21.9(b) states that if "a primary recipient extends Federal financial assistance to any other recipient, such other recipient shall also submit such compliance reports to the primary recipient as may be necessary to enable the primary recipient to carry out its obligation under this part." PURPOSE OF THE TITLE VI REPORT The purpose of this report is to document the City of Costa Mesa's sub -recipient compliance with Title VI. This report was prepared and submitted to the Orange County Transportation Authority's (OCTA) Office of Civil Rights on May 1, 2012. This report was prepared with the assistance of OCTA and in accordance with FTA Circular 4702.1 B issued April 30, 2012. PROGRAM OVERVIEW The City of Costa Mesa received FTA 5307 grant funds from OCTA for the construction of a Class I multipurpose trail in Fairview Park. FTA 5307 funding of $500,000 was matched with $321,000 by the City for a project cost of $821,000. The project consists of a Y mile, 8 -foot wide concrete trail with decomposed granite paths, cable rail fencing, signage, and landscaping. The project is scheduled to be completed by August 2012. GENERAL REQUIREMENTS SELF -CERTIFICATION FORM See Attachment A. NOTICE OF TITLE VI PROTECTION Protecting Your Rights: The City of Costa Mesa operates all of its services, programs and activities without regard to race, color, or national origin in accordance with Title VI of the Civil Rights Act of 1964. Any person who believes that he or she, or as a member of a specific group, has been subjected to discrimination, may file a signed Title VI complaint with the City. The City of Costa Mesa prohibits intimidation, coercion, or engagement in other discriminatory conduct against anyone because he or she has filed a complaint to secure rights protected by Title VI. How Do I File a Title VI Complaint If you believe you have been discriminated against, you may file a signed, written complaint within one hundred and eighty (180) days of the date of alleged discrimination. The complaint should include the following information: • Your name, address and contact information (ex: telephone number, e-mail address, etc.) • How, when, where and why you believe you were discriminated against. Include the location, names and contact information of any witnesses. The complaint may be filed in writing to the City of Costa Mesa directly at: City of Costa Mesa Human Resources Department 77 Fair Drive P.O. Box 1200 Costa Mesa, CA 92628 To file a complaint in person, please visit City Hall at: 77 Fair Drive Costa Mesa, CA 92628 For more information regarding Title VI, please call: 714.754.5369 The City of Costa Mesa has developed the notice of Title VI protection. The City of Costa Mesa utilized OCTA guidance to develop the notice. The City of Costa Mesa utilized (website, poster, and flyers) to notify the public of their rights under Title VI. The notification is available at City Hall, 77 Fair Drive and the city's website, www.costamesaca.gov. A copy of the notice is presented in Attachment B. COMPLAINT PROCEDURE AND FORM The City of Costa Mesa has developed a Title VI complaint procedure. The City of Costa Mesa utilized (FTA and/or OCTA guidance) to develop the notice. The City of Costa Mesa utilized (website, poster, and flyers) to notify the public of their rights under Title VI. The notification is available at City Hall, 77 Fair Drive and the city's website, www.costamesaca.gov. A copy of the notice is presented in Attachment C. LIST OF ACTIVE COMPLAINTS/INVESTIGATIONS/LAWSUITS The City of Costa Mesa has no active Title VI complaints, investigations or lawsuits alleging discrimination on the basis of race, color, or national origin. PUBLIC PARTICIPATION PLAN The City shall seek out and consider viewpoints of minority, low-income, and LEP populations in the course of conducting public outreach and involvement activities in regard to proposed transportation decisions. The City shall make every effort to include the following practices consistent with the City's adopted public participation plan: 1. Coordination with individuals, institutions, or organizations and implementing community-based public involvement strategies to reach out to members in the affected minority and/or low-income communities; 2. Provision of opportunities for public participation through means other than written communication, such as the use of audio or video recording devices to capture oral comments; 3. Utilization of locations, facilities and meeting times that are convenient and accessible to low- income and minority communities; 4. Utilization of different meeting sizes or formats, or varying the type and number of news media used to announce public participation opportunities. 5307 FTA Funding Outreach as Part of NEPA Analysis During the NEPA and CEQA process for the Fairview Channel Multipurpose Trail process, a Preliminary Environmental Study was performed. The project site is an existing public park, Fairview Park, which is open to the public seven days per week. During informational meetings with the public it was determined that the project does not go through any minority or low-income census tracts, does not require the relocation of any public utilities, will not require the relocation of any residents or businesses, and does not encroach upon Tribal land. In addition to conducting neighborhood informational meetings during the planning stages of the project, the City Council and Parks and Recreation Commission also reviewed and approved the project elements at their public meetings. LIMITED ENGLISH PROFICIENCY PLAN Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English can be limited English proficient, or "LEP." These individuals may be entitled to language assistance with respect to a particular type of service, benefit, or encounter. Federal laws particularly applicable to language access include Title VI of the Civil Rights Act of 1964, and the Title VI regulations, prohibiting discrimination based on national origin, and Executive Order 13166 issued in 2000. Many individual federal programs, states, and localities also have provisions requiring language services for LEP individuals. An Executive Order is an order given by the President to federal agencies. The LEP Executive Order (Executive Order 13166) states that people who are LEP should have meaningful access to federally conducted and federally funded programs and activities. Executive Order 13166 requires all agencies that provide federal financial assistance to issue guidance on how recipients of that assistance can take reasonable steps to provide meaningful access consistent with Title VI and the Title VI regulations. The Order also requires that federal agencies create plans for ensuring that their own activities also provide meaningful access for persons who are LEP. The City of Costa Mesa will provide a means of communication to individuals whom English is not their primary language and who have a limited ability to read, write, speak, or understand English. As an FTA sub -recipient, the City of Costa Mesa will adopt the OCTA Limited English Proficiency (LEP) Plan, which can be found at www.octa.net. MEMBERSHIP OF DECISION-MAKING BODIES The table below depicts the membership of the City of Costa Mesa's non -elected decision-making bodies broken down by race. "Information obtained from 2012 U.S. Census. All City of Costa Mesa commissions and committees are open to Costa Mesa residents regardless of race, color, or national origin. The application for commission and committees is available online at www.costamesaca.gov and at City Hall, 77 Fair Drive, City Clerk's office. . The City will continue its practice of identifying discrimination based on race, color, religion, sex, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity and source of income, and where such discrimination is found to exist, implementing programs or practices to eliminate the discrimination. Programs include, but are not limited to, hiring MinorityMomen/Disadvantaged Business Enterprises (DBE) contractors, providing translations through the LEP Program, and conducting public outreach and involvement in City projects. City staff will continue to update and disseminate Title VI Program information to City employees, sub -recipients, contractors, Affected Parties, and the general public. Public dissemination efforts may include: posting public statements setting forth the City's non-discrimination policy; inclusion of Title VI Assurances in City contracts and grants; and publishing a Title VI Policy Statement in a newspaper of general circulation in the City and in other community/minority publications at least once annually; posting a Title VI Policy Statement in vicinity of proposed City projects; and including a Title VI Policy Statement in announcements of hearings and meetings; and providing notice of City Proposed Projects to minority communities. Each Department Head is responsible for Title VI compliance for individual projects. Compliance activities include, but are not limited to: 1. Ensuring that all aspects of a Proposed Project's planning process and operations comply with the Title VI Requirements. 2. Ensuring that Affected Parties have meaningful access to a Proposed Project's planning processes. 3. Assisting the Title VI Coordinator in gathering and organizing data for the Title VI Plan Report. African Asian/Pacific Native Body Caucasian Hispanic American Islander American American Costa Mesa Population 54% 34.6% 1.1% 9.7% 0.6% Costa Mesa 80% 20% 0% 0% 0% Planning Commission Costa Mesa 100% 0% 0% 0% 0% Parks & Recreation Commission "Information obtained from 2012 U.S. Census. All City of Costa Mesa commissions and committees are open to Costa Mesa residents regardless of race, color, or national origin. The application for commission and committees is available online at www.costamesaca.gov and at City Hall, 77 Fair Drive, City Clerk's office. . The City will continue its practice of identifying discrimination based on race, color, religion, sex, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity and source of income, and where such discrimination is found to exist, implementing programs or practices to eliminate the discrimination. Programs include, but are not limited to, hiring MinorityMomen/Disadvantaged Business Enterprises (DBE) contractors, providing translations through the LEP Program, and conducting public outreach and involvement in City projects. City staff will continue to update and disseminate Title VI Program information to City employees, sub -recipients, contractors, Affected Parties, and the general public. Public dissemination efforts may include: posting public statements setting forth the City's non-discrimination policy; inclusion of Title VI Assurances in City contracts and grants; and publishing a Title VI Policy Statement in a newspaper of general circulation in the City and in other community/minority publications at least once annually; posting a Title VI Policy Statement in vicinity of proposed City projects; and including a Title VI Policy Statement in announcements of hearings and meetings; and providing notice of City Proposed Projects to minority communities. Each Department Head is responsible for Title VI compliance for individual projects. Compliance activities include, but are not limited to: 1. Ensuring that all aspects of a Proposed Project's planning process and operations comply with the Title VI Requirements. 2. Ensuring that Affected Parties have meaningful access to a Proposed Project's planning processes. 3. Assisting the Title VI Coordinator in gathering and organizing data for the Title VI Plan Report. 4. Reviewing the Department work programs, policies, and other directives to ensure compliance with the Title VI Requirements. 5. Verifying the level of participation of Affected Parties at public outreach meetings. CITY COUNCIL APPROVAL The Costa Mesa City Council met on April 17, 2012 to review and approve the Title VI Plan document. A copy of the Council minutes approving of the plan is presented in attachment D. The City of Costa Mesa is a non -transit provider and is not required to submit the requirements as specified in Chapters IV, V or VI of the FTA Circular 4702.1 B. Individual Who Completed the Plan Document: Robert Staples Contract Administrator City of Costa Mesa Public Services Division 77 Fair Drive Costa Mesa, CA 92628 ATTACHMENT A ATTACHMENTB ATTACHMENT C ATTACHMENTS Self Certification Form Notice of Title VI Protection Complaint Procedure and Complaint Form ATTACHMENT D Governing Board Resolution/Meeting Minutes ATTACHMENT A OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 Subgrantee:_ L ('�'� Or 60,;7)4 HezjP Grant No.(s): C ^ D ~ 14 4 Z Project Description: /�v��'``� CO-UPeL 14V1T)AJRP05;6 7)eA-j (- The following declarations and information are hereby provided related to the above - referenced FTA -funded project during the past fiscal year: I. GENERAL CERTIFICATIONS (to be completed by all sub zrantees) A. Financial Do you have the financial capacity to match FTA grant funds/FTA funded grant projects? Yes X No 2. Are your invoices being properly recorded and sent to OCTA by a supervising project manager with knowledge of FTA Compliance? Yes_4X No 3. Are indirect costs being charged to grants? Yes No x If yes, do you have a cost allocation plan to support indirect administrative costs related to a grant program? Yes No 4. Have annual single audits been conducted? Yes No X If Yes, please supply a copy to OCTA. 5. Are there any unresolved compliance issues in the single audits conducted in the past three (3) years? Yes No n 6. Have any internal, state, or local government audit reports had findings relating to FTA program requirements? Yes No If Yes, please supply a copy to OCTA B. Satisfactory Continuing Control 1. Did you make incidental use of any FTA -funded property? Yes No X a. If yes, was FTA approval obtained? Yes_ No 2. Do you maintain continuing control over the property? YesX No 3. Is revenue generated used for transit purposes? Yes No x Page 1 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 C. Procurement 1. Do you have procurement policies and procedures that conform to applicable federal laws? Yes X No 2. Do any potential conflicts of interest exist between policy board member/employees and consultants/vendors/suppliers or between a management contractor and consultants/vendors/suppliers? Yes No X Do you allow for full and open competition for all transaction under the following methods of procurement? a. Micro -Purchases ($2,500 or less) Yes —No -6 b. Small Purchases (More than $2,500, but not more than $100,000) Yes _ No J c. Sealed Bids/Invitation for Bid (IFB) Yes X No d. Competitive Proposals/Request for Proposals (RFP) Yes X No e. Architectural and Engineering Services (A&E) Yes)( No f. Revenue Contracts Yes No-& D. Disadvantaged Business Enterprise (DBE) Did you receive any complaints alleging that you did of comply with the DBE regulations in the past three (3) years? Yes No 2. Did you award a contract to a firm that did not meet specific DBE contract goals? Yes No A If Yes, how was it determined if "good faith efforts" by the firm were sufficient? E. Lobbying Has your agency included the lobbying clause in all agreements and procurement solicitations exceeding $100,000? Yes No 2 Has the grantee used non-federal funds for lobbying activities? Yes Nq(-<— If yes, have the proper disclosures been made and filed with FTA on standard form LLL? Yes No Have 11 disclosures been updated quarterly if needed and so reported? Yes Ix No F. Title VI - Civil Rights Compliance 1. Who at your agency is re onsible or ensuring Title V compliance? Name: J}V W(AN KEj0 L=5 f4�.NiP'�jeg 2. Do you have a Title VI complaint process? Yes X No Page 2 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 3. Have you received any Title VI complaints during the past year? Yes No_)(_ a. If yes, please explain: G. Public Comment Process for Fare and Service Chan es 1. Do you have a locally developed process for soliciting and considering public comments prior to a fare increase or major service reduction? Yes No N l A 2. Have you raised a fare or carried out a major reduction in service in the past three (3) years? Yes No PA a. If yes, please explain: A. Americans with Disabilities Act (ADAM 1. Have you received any ADA -related complaints during the past year? Yes No x a. If yes, please explain: I. Safety and Security 1. Do you have a written policy on safety �ned by the General Manager or the Board of Directors Chairperson? Yes No 2. Do you have a written system safety program plan (SSPP) for its transit services? Yes No a [ A J. Drug -Free Workplace 1. Have you established a drug-free workplace according to state and federal requirements? Yes X No 2. Has any employee reported to you a criminal conviction for a drug sta�ilte violation that occurred in the workplace? . Yes No IL a. If yes, was the FTA notified? Yes No K. Drug and Alcohol Program 1. Do you and/or your contractors and subcontractors have a drug and alcohol testinXKrogram for safety sensitive employees as defined by FTA? ( Yes No Page 3 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 2. Do you and/or your contractors and subcontractors conduct the following drug and alcohol tests: i. Pre -Employment (drugs only)? Yes No ii. Random? iii. Post -Accident? iv. Reasonable suspicion? V. Return to duty? vi. Follow-up? Yes No X Yes X_ No Yes No Yes No Yes No J_ 3. Do you and/or your contractors and subcontractors use drug testing laboratories certified y the U.S. Department of Health and Human Services (DHHS)? Yes No L. Equal Employment Opportunity (EEO) (applicable for 50 or more employees) 1. Who at your agency is responsible for ensuring that EEO obligationsare fulfilled?WMVo e 44 2. Have you received ny EEO complaints during the past three (3) years? Yes No a. If yes, please explain: M. Technical 1. How do you monitor contractors/lessees to ensure compliance with FTA requirements? I N(.LIV - 1P UTR�k� ,Dora rt�w3 . centers, bus shelters, etc.) A. Satisfactory Continuing Control 1. Did you dispose of any FTA -funded real property or equipment? Yes No If yes, please attach a list of the property/equipment disposed of to this form. Page 4 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 2. Was any real property or equipment removed from public transit service before the end of its service life? Yes No If yes, was FTA notified? Yes No B. Maintenance 1. Do you have a current written maintenance plan for your federally funded facilities and equipment? Yes No 2. Does the plan include a program of inspections and preventative maintenance activities to ensure that assets are protected from deterioration and reach their maximum useful life? Yes No 3. Does the maintenance plan prescribe a record keeping system for permanently recording the maintenance history of the equipment/facility? Yes No 4. Are your federally funded facilities/equipment being maintained on time and in accordance with your maintenance plan? Yes No C. Procurement 4 1. Have all construction contracts greater than $2,000, incorporated the Davis -Bacon Act Requirements? Yes No 2. Have you included a Buy America provision for all procurement of steel, iron and manufactured products, except products with a waiver or small purchases of $100,000 or less? Yes No 3. Have you obtained and retained Buy America certifications from successful vendors for purchases of more than $100,000? Yes No III. VEHICLE CERTIFICATIONS (to be completed only for rolling stock procurements i.e. paratransit vehicles, buses, support vehicles etc.) A. Satisfactory Continuing Control 13 1. Do you have equipment records that provide the following information: i. Description? Yes No ii. I.D. Number? Yes No Page 5 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 iii. Acquisition date? Yes No iv. Cost? Yes No V. Federal percentage? Yes No vi. Grant Number? Yes No vii. Location? Yes No viii. Use and condition? Yes No ix. Disposition action? Yes No X. Vested title? Yes No 2. Did you dispose of any FTA-f4nded equipment_? Yes No 1 (� If yes, please attach a list of the'equipment disposed of to this form. 3. Was any equipment removed from public transit rvice before the end of its oservice life? Yes No a. If yes, was FTA notified? Yes No 4. Do you have any federally funded equipmen this operated by contractors? Yes No j a. If yes, do you maintain control of the equipment? Yes No 5. Please attach a list of all FTA -funded equipment with the current odometer reading for each of your vehicles. B. Maintenance 1. Do you or your contractor have a current written vehicle maintenance plan for your federally funded rolling stock? Yes No 2. Is the written maintenance p an you use consistent with the manufacturer's minimum maintenance requirements for vehicles under warranty? Yes No � j t Page 6 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 3. Are your vehicle preventative maintenance inspections completed on time and consistent with your established maintenance plan? No 4. Are maintenance procedures for wheelchair lift�a�fl other accessibility equipment included in your maintenance plan and preventative maintenance inspections? Yes No 5. Are lifts and accessibility features repaired pro as required by the DOT ADA regulations? Yes No C. Procurement 1. Have you included a Buy America provision for all procurement .of steel, iron and manufactured products, except products with a waiver or small purchases of $100,000 or less? YesX No 2. Have you obtained and retained Buy America certifications from successful vendors for purchases of more than$100,000? Yes,? No, D. Charter Service 1. Have you used an federally funded rolling stock for charter service? Yes N0 If yes, was all charter service incidental service? Yes No If yes, were records kept to fully recover the life of the property (i.e. were charter use days/miles subtracted from vehicles total service days/miles)? Yes No 2. Have any complaints been filed alleging that you have c�aducted charter service in violation of FTA regulations? Yes No E. School Bus 1. Have you operated exclusive school bus service?Yes No 2. Have you provided school "tripper service?" Yes No Page 7 of 8 OCTA PASS-THROUGH GRANTEE ANNUAL FTA COMPLIANCE SELF -CERTIFICATION FY 2010-2011 By signing below, I, on behalf of the aforementioned subgrantee, declare that the information provided within this certification is true and correct to the best of my knowledge and that I am authorized to make this declaration on behalf of my agency. Signature Date 4Fa0-42.0r /A e__; tR Print Name &Qg-c4 Nlu air Title By signing below, I, as the aforementioned subgrantee's contractor, declare that the information provided as it pertains to my operations for said subgrantee is true and correct to the best of my knowledge and that I am authorized to make this declaration on behalf of my firm. � 8 Signature I E6e Agency/Company Name Page 8 of 8 ATTACHMENT B Costa Mesa Notification of Title VI Protection The City of Costa Mesa operates all of its services, programs and activities without regard to race, color, or national origin in accordance with Title VI of the Civil Rights Act of 1964. Any person who believes that he or she, or as a member of a specific group, has been subjected to discrimination, may file a signed Title VI complaint with the City. The City of Costa Mesa prohibits intimidation, coercion, or engagement in other discriminatory conduct against anyone because he or she has filed a complaint to secure rights protected by Title VI. If you believe you have been discriminated against, you may file a signed, written complaint within one hundred and eighty (180) days of the date of alleged discrimination. The complaint should include the following information: -Your name, address and how to contact you (e.g. telephone number, e-mail address, etc.) -How, when, where and why you believe you were discriminated against. Include the location, names and contact information of any witnesses. The complaint may be filed in writing to the City of Costa Mesa directly to: City of Costa Mesa Human Resources Department 77 Fair Drive P.O. Box 1200 Costa Mesa, CA 92628 To file a complaint in person, please visit City Hall at: 77 Fair Drive Costa Mesa, CA 92628 For more information regarding Title VI, please call: 714.754.5369 ATTACHMENT C Title VI Complaint Form CITY OF COSTA MESA Office of Civil Rights Title VI of the Civil Rights Act of 1964 provides that "no person in the United States shall, on the grounds of race, color or nation of origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance". It is the policy of the City of Costa Mesa to employ its best efforts to ensure that all programs, services, activities, and benefits are implemented in a non-discrimination manner. Any person who believes that he or she, individually, or as a member of any specific class of persons, have been subjected to discrimination on the basis of race, color, or national origin may file a written complaint within 180 days after the date of the alleged discrimination with the City of Costa Mesa, the FTA or the Secretary of Transportation. Further, the City of Costa Mesa prohibits intimidation, coercion, or engagement in other discriminatory conduct against anyone because he or she has filed a complaint to secure rights protected by Title VI. Please provide the following information: Your Name Phone Number Street Address City State Zip Code Person(s) discriminated against (if someone other than complainant) Street Address City State Zip Code Date of Incident: Which of the following best describes the reason the alleged discrimination took place (circle one) • Race • Color • National Origin (Limited English Proficiency) If you are unable or incapable of providing a written statement, but wish the City of Costa Mesa to investigate alleged discrimination; a verbal complaint of discrimination may be made. Please contact the Human Resources Dept., 714.754.5369. The complainant will be interviewed by an appropriate official authorized to receive complaints. If necessary, the official will assist you in converting verbal complaints to writing. Translation services will be provided to all complainants, as necessary. All complaints must, however, be signed by the complainant or his/her representative. Please describe the alleged discrimination incident. Provide the names and title of all OCTA employees involved if available. Explain what happened and whom you believe was responsible. Please use the back of this form if additional space is required. Please mail your complaint form directly to the City of Costa Mesa to the following address: City of Costa Mesa Human Resources Department 77 Fair Drive P.O. Box 1200 Costa Mesa, CA 92628 To file a complaint in person, please visit City Hall at: 77 Fair Drive Costa Mesa, CA 92628 Have you filed a complaint with any other federal, state or local agency? (Circle one) Yes/No Agency Contact Person Street Address, City, State, Zip Code Agency Contact Person Street Address, City, State, Zip Code Listed below are the state and federal addresses if you wish to file a Title VI complaint directly with one or both of these agencies. State Office Federal Transit Administration Region IX Office of Civil Rights 201 Mission Street, Suite 1650 San Francisco, CA 94105-1839 Federal Office Federal Transit Administration Office of Civil Rights Title VI Program Coordinator East Building 5th Floor — TCR 1200 New Jersey Avenue, SE Washington, DC 20590 I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief. Complainant's Signature Date