HomeMy WebLinkAbout2024-EO-2a Executive Order Approving Title VI Implementation Plan & Policy for the City of Jeffersonville OFFICE OF THE MAYOR FOR THE CITY OF JEFFERSONVILLE
STATE OF INDIANA
EXECUTIVE ORDER 2024-EO-2
AN EXECUTIVE ORDER APPROVING TITLE VI IMPLEMENTATION PLAN
AND POLICY FOR THE CITY OF JEFFERSONVILLE
WHEREAS, the federal government enacted Title VI of the Civil Rights Act of 1964,
which prohibits discrimination based on race, color,religion, national origin and sex; and
WHEREAS, since the Civil Rights Act was approved,additional regulations,statutes,and
executive orders prohibiting discrimination have expanded the number of protected categories;
and
WHEREAS, as the City of Jeffersonville is a recipient of federal funds, its activities,
regardless of funding, are required to comply with Title VI of the Civil Rights Act of 1964, and
related regulations, statutes and executive orders; and
WHEREAS, it is a requirement of the Indiana Department of Transportation and the U.S.
Department of Transportation that entities receiving federal financial assistance adopt a Title VI
Implementation Plan; and
WHEREAS, the City of Jeffersonville has prepared a Title VI Implementation Plan
(attached hereto as Exhibit "A") which will take effect immediately to reflect the Title VI
requirements, and to report on the City's Title VI plan; and
NOW, THEREFORE, IT IS ORDERED by the Mayor of Jeffersonville that the
proposed Title VI Implementation Plan is hereby adopted.
(1_,
SO ORDERED on this 10th day of October, 2024.
Mayor Mike oore
ATTEST:
Lisa Gill, Clerk
EXHIBIT "A"
TITLE VI IMPLEMENTATION PLAN AND POLICY
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CITY OF JEFFERSONVILLE
TITLE VI IMPLEMENTATION PLAN
2024-2025
Table of Contents
INTRODUCTION 3
CITY OF JEFFERSONVILLE TITLE VI NON-DISCRIMINATION NOTICE & POLICY 3
TITLE VI ASSURANCES & IMPLEMENTATION 5
CITY OF JEFFERSONVILLE ORGANIZATION AND STAFFING 6
CITY OF JEFFERSONVILLEOVERVIEW OF TITLE VI PROGRAM: DATA COLLECTION, ANALYSIS & REPORTING 7
COMPLAINTS OF DISCRIMINATION 7
HOW TO FILE A COMPLAINT? 7
ELEMENTS OF A COMPLETE COMPLAINT 8
PROCESSING COMPLAINTS 8
ENVIRONMENTAL JUSTICE ANALYSIS & REPORTS 9
LIMITED ENGLISH PROFICIENCY (LEP) POLICY 10
SUMMARY OF THE FOUR FACTOR ANALYSIS 10
SUMMARY OF LEP ACCOMMODATION PLAN 12
TITLE VI TRAINING 12
EMPLOYER/EMPLOYEE DISSEMINATION & TRAINING 12
PUBLIC INVOLVEMENT 13
DATA COLLECTION 13
COMMUNITY INVOLVEMENT & OUTREACH 14
REVIEW OF PROGRAM AREA 14
ANNUAL WORK PLAN 14
APPENDIX 16
APPENDIX A:ASSURANCES 17
APPENDIX B:COMPLAINT POLICY 22
APPENDIX B-1:COMPLAINT FORM/RELEASE 24
APPENDIX C:COMPLAINT LOG 34
APPENDIX D: EXTERNAL COMPLAINT PROCEDURE 22
APPENDIX D-1: EXTERNAL COMPLAINT FORM 38
APPENDIX E:VOLUNTARY INVOLVEMENT SURVEY 42
APPENDIX F: I-SPEAK CARDS 45
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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INTRODUCTION
This Title VI Implementation Plan is a part of the City of Jeffersonville continual and ongoing effort to proactively
meet and exceed the minimum compliance requirements established under Title VI of the Civil Rights Act of 1964
(Title VI), 49 CFR § 26, and the related anti-discrimination statutes and regulations. With this Implementation
Plan, City of Jeffersonville seeks to provide continued transparency, clarity and technical guidance for internal
and external constituents regarding its Title VI program.
CITY OF JEFFERSONVILLE TITLE VI NON-DISCRIMINATION NOTICE & POLICY
City of Jeffersonville values each individual's civil rights and wishes to provide equal opportunity and
equitable service for the citizens of this state. As a recipient of federal funds, City of Jeffersonville conforms
to Title VI and all related statutes, regulations, and directives, which provide that no person shall be excluded
from participation in, denied benefits of, or subjected to discrimination under any program or activity
receiving federal financial assistance from City of Jeffersonville on the grounds of race, color, age, sex, sexual
orientation, gender identity, disability, national origin, religion, income status or limited English proficiency.
City of Jeffersonville further assures every effort will be made to ensure nondiscrimination in all of its
programs and activities, regardless of whether those programs and activities are federally funded.
It is the policy of City of Jeffersonville to comply with Title VI of the Civil Rights Act of 1964; Title VII of the
Civil Rights Act of 1964,42 U.S.C. § 2000e; Age Discrimination Act of 1975, 42 U.S.C. §§ 6101-6107; Uniform
Relocation Assistance and Real Property Acquisition Policies Act of 1970, 42 U.S.C. §§4601-4655; 1973
Federal Aid Highway Act, 23 U.S.C. § 324; Title IX of the Education Amendments of 1972, Pub. L. No. 92-318,
86 Stat. 235; Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. §§ 701 et seq; Civil Rights Restoration
Act of 1987, Pub. L. No. 100-259, 102 Stat. 28; Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 et
seq.; Title VIII of the Civil Rights Act 1968, 42 U.S.C. §§ 3601-3631; Exec. Order No. 12898, 59 Fed. Reg. 7629
(1994) (Federal Actions to Address Environmental Justice in Minority Populations and Low-Income
Populations); and Exec. Order No. 13166, 65 Fed. Reg. 50121 (2000) (Improving Access to Services for
Persons with Limited English Proficiency).
The Civil Rights Restoration Act of 1987, Pub. L. No. 100-259, 102 Stat. 28, broadened the scope of Title VI
coverage by expanding the definition of terms "programs or activities" to include all programs or activities of
federal-aid recipients, subrecipients and contractors/consultants, regardless of whether such programs and
activities are federally assisted.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Pursuant to the requirements of Section 504 of the Rehabilitation Act of 1973, Pub. L. No.93-112,87 Stat.
355, City of Jeffersonville hereby gives assurance that no qualified disabled person shall, solely by reason of
disability, be excluded from participation in, be denied the benefits of or otherwise be subjected to
discrimination, including discrimination in employment, under any program or activity that receives or
benefits from this federal financial assistance.
City of Jeffersonville also assures that every effort will be made to prevent discrimination through the
impacts of its programs, policies and activities on minority and low-income populations. In addition, City of
Jeffersonville will take reasonable steps to provide meaningful access to services for persons with limited
English proficiency(LEP). City of Jeffersonville will,where necessary and appropriate, revise, update and
incorporate nondiscrimination requirements into appropriate manuals, directives and regulations.
Whenever City of Jeffersonville distributes federal-aid funds to a second-tier subrecipient,City of
Jeffersonville will include Title VI language in all written agreements.
The following individual has been identified as City of Jeffersonville's Title VI and ADA Coordinator and is
responsible for initiating and monitoring Title VI activities, preparing reports and performing other
responsibilities, as required by 23 C.F.R. § 200 and 49 C.F.R. § 21.
Andy Crouch
Title VI/ADA Program Manager
500 Quartermaster Ct.
Jeffersonville, IN 47130
(812) 285-6476
acrouch@cityofjeff.net
City of Jeffersonville affirms its commitment to nondiscrimination annually by publishing its Annual Title VI
Implementation Plan and reaffirming its Assurances of Nondiscrimination, incorporated herein (see next
page).
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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TITLE VI ASSURANCES & IMPLEMENTATION
Fully executed Assurances are included in Appendix A and integrated into this document. This Title VI
Implementation Plan has been adopted, implemented and is being adhered to by City of Jeffersonville. City of
Jeffersonville has implemented this plan by Executive Order 2024-EO-2 and it is effective immediately. This plan
will be renewed on or befor J nuary 1, 2026.
Signed by: &19- Date: 0 \ 0`aL(
Mayor Mike Moore
The individual above is a duly authorized representative of City of Jeffersonville
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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CITY OF JEFFERSONVILLEORGANIZATION AND STAFFING
Electorate
, I ,
I I I
City Council Mayor Clerk
Board of Public Works&
Safety
I - -- / , / 1
Infrastructure Citizen Services Administrative
Engineering Animal Shelter -[ Legal
J
Street - Fire —( Human
Wastewater Police ---( Finance
J /
Utility Billing ...4Parks & Recreation -4.Redevelopment
Stormwater Sanitation —(Planning/Zoning
Building Commission Communications
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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CITY OF JEFFERSONVILLEOVERVIEW OF TITLE VI PROGRAM: DATA COLLECTION, ANALYSIS &
REPORTING
The type of data collected is dependent on the program area's objective. City of Jeffersonville collects
various types of data to ensure compliance with Title VI. Some information is collected for a period of
time with the objective of determining what data needs to be collected.
The following types of data are currently being collected by City of Jeffersonville:
• Complaints received, logged, processed and investigated by City of Jeffersonville
• Environmental Justice analysis and reports
• Limited English Proficiency reports
• Title VI Training
• Public Involvement Survey
• Records of meeting minutes and discussions related to Title VI in all program areas.
• City of Jeffersonville collects data related to specific program areas being reviewed this year for
disparate/ disproportionate impacts or other evidence of potential discrimination or
discriminatory outcomes.
COMPLAINTS OF DISCRIMINATION
HOW TO FILE A COMPLAINT?
While a Complainant may preliminarily submit his or her complaint by online form submission, mail, facsimile, or
email to the Title VI Coordinator, a signed, original copy of the complaint must be mailed to the Title VI
Coordinator to officially begin the complaint process. Any person with a disability may request to file his or her
complaint using an alternative format. City of Jeffersonville does not require a Complainant to use the City of
Jeffersonville complaint form when submitting his or her complaint.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Direct all complaints of discrimination pursuant to Title VI to:
Andy Crouch, City Engineer
500 Quartermaster Ct.
Jeffersonville, IN 47130
acrouch@cityofjeff.net
812-285-6476
Fax 812-280-4703
ELEMENTS OF A COMPLETE COMPLAINT
A complaint must be both written and signed to be complete. Verbal complaints must be reduced to writing and
provided to the Complainant for confirmation, review and signature before processing. The complaint form is
available for download from the City of Jeffersonville website at:www.cityofjeff.net
Additionally, a complaint must include the following information:
• The full name and address of the Complainant;
• The full name and address of the Respondent,the individual, agency, department or program that
allegedly discriminated against Complainant; and
• A description of the alleged discriminatory act(s)that violated Title VI (i.e., an act of intentional
discrimination or one that has the effect of discriminating on the basis of race,color, national origin, sex,
age or disability)and the date of occurrence.
f PROCESSING COMPLAINTS
The Title VI Coordinator will process all complaints. The Title VI Coordinator is responsible for:
• The Title VI Coordinator will review the complaint upon receipt to ensure that all required information is
provided,the complaint meets the filing deadline date which is 180 days from the date the alleged
discriminatory act occurred, and falls within the jurisdiction of the City.
• The Title VI Coordinator will then investigate the complaint. If the complaint is against the City then the
Mayor's office or their designee will investigate the complaint.Additionally, a copy of the complaint will
be forwarded to the City Attorney.
• If the complaint warrants a full investigation,the Complainant will be notified in writing by certified mail.
This notice will name the investigator and/or investigating agency.
• The party alleged to have acted in a discriminatory manner will also be notified by certified mail as of the
complaint.This letter will also include the investigator's name and will request that this party be
available for an interview.
• Any comments or recommendations from legal counsel will be reviewed by the Title VI Coordinator,
Board of Public Works and Mayor's office.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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• Once the City has investigated the report findings, the City will adopt a final resolution.
• All parties associated with the complaint will be properly notified of the outcome of the City's
investigative report.
• If the complainant is not satisfied with the results of the investigation of the alleged discriminatory
practice(s), she/he shall be advised of their right to appeal the City's decision. Appeals must be filed
within 180 days after the City's final resolution. Unless new facts not previously considered come to light,
reconsideration of the City's determination will not be available.
• The foregoing complaint resolution procedure will be implemented in accordance with the Department
of Justice guidance manual entitled "Investigation Procedures Manual for the Investigation and
Resolution of Complaints Alleging Violations of Title VI and Other Nondiscrimination Statues," available
online at: http://www.justice.gov/crt/about/cor/Pubs/manuals/complain.pdf
ENVIRONMENTAL JUSTICE ANALYSIS & REPORTS
In accordance with Title VI of the Civil Rights Act of 1964, each Federal agency shall ensure that all
programs or activities receiving Federal financial assistance that affect human health or the
environment do not directly, or through other arrangements, use criteria, methods, or practices that
discriminate on the basis of race, color, or national origin. Part of Title VI reads, "No person in the
United States shall, on the ground of race, color, or national origin be excluded from participation in, be
denied the benefits of, or be subject to discrimination under any program or activity receiving Federal
financial assistance."
The three fundamental environmental justice (EJ) principles are:
• To avoid, minimize, or mitigate disproportionately high and adverse human health and
environmental effects, including social and economic effects, on minority populations and low-
income populations;
• To ensure the full and fair participation by all potentially affected communities in the
transportation decision-making process; and
• To prevent the denial of, reduction in, or significant delay in the receipt of benefits by minority
populations and low-income populations.
City of Jeffersonville is committed to these three environmental justice principles in all work that the
City performs.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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LIMITED ENGLISH PROFICIENCY (LEP) POLICY
On August 11, 2000, the President signed an executive order, Executive Order 13166: Improving Access
to Service for Persons with Limited English Proficiency (LEP), to clarify Title VI of the Civil Rights Act of
1964. It has as its purpose, to ensure meaningful access to programs and services to otherwise eligible
persons who are not proficient in the English language. In addition, The US Department of
Transportation published Policy Guidance Concerning Recipients' responsibilities to Limited English
Proficient Person in the December 14, 2005 Federal Register. This guidance outlines the following four
factors that the City uses to access the LEP populations in City of Jeffersonville.
1. The number and proportion of LEP persons eligible to be served or likely to be encountered by
the City.
2. The frequency with which LEP individuals come into contact with the program, activity or
service.
3. The nature and importance of the program, activity, or service provided by the program.
4. The resources available to the City and costs.
In addition, City of Jeffersonville has not implemented the safe harbor provision whereby it identifies
and translate all vital documents into any language where the 5% threshold is met whereby 5% or more
of the population in the county both:
• Does not speak English very well AND
• Primarily speaks another specific language as identified in current census data or other
publically available records.
SUMMARY OF THE FOUR FACTOR ANALYSIS
Factor 1:
The number and proportion of LEP persons eligible to be served or likely to be encountered by the City
can only be estimated until the actual number of persons who can speak English less than "very well"
are documented as needing assistance by City Staff. With this Title VI Plan being in early development
stages and considered a document that may need regular updates, US Census Bureau information is
being used at this time. The total population is provided below to shown general distribution of race
and ethnicity in the community. The estimated number of persons that may not speak English "very
well" is following in the US Census Bureau 2006-2010 American Community Survey.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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The U.S. Census Bureau provides statistics from 2020 for the City of Jeffersonville as follows:
Total population =49,447
Population by Ethnicity:
Hispanic or Latino =3,021 Non-Hispanic or Latino = 35,271
Population by Race:
White = 36,036, African American = 6,979, Asian = 742, American Indiana or Alaska Native = 193, Native
Hawaiian and Pacific Islander = 101, Other = 1,396, Identified by two or more = 4,000.
The US Census Bureau 2006-2010 American Community Survey 5-Year Estimates under SELECTED
SOCIAL CHARACTERISTICS estimates the number of people in City of Jeffersonville who speak a
language other than English to be 1,049 with those speaking English less than "very well" estimated at
21.8% or approximately 307 individuals who may be considered limited in English proficiency. The
margin of error is +/-10.3% so the actual number may fluctuate from 452 to 162 individuals.
According to the census numbers above there may be up to 452 individuals who live in the City of
Jeffersonville that may be considered as LEP. Based on actual contact between City Staff and the
community there have been very few requests from anyone in the service area asking the City to
provide language translation services. Therefore, the LEP population is probably even less than the
estimate shown above.
Factor 2: The frequency with which LEP individuals come into contact with the program, activity or
service:
Due to the infrequent requests for translation services, there appears to be a minimal need for
translation services from the City. This may be attributed to the high percentage of younger people
(87.6%for ages up to 17) who are available as family members for translation services.
Factor 3: The nature and importance of the program, activity, or service provided by the program:
If at any time a LEP individual requests translation services that are considered important such that
denial or delay of access or services or information could have serious or even life-threatening
implications, the City will provide, upon request, services to assist the LEP population including
translation of vital City documents and interpretation services.
Factor 4: The resources available to the City and costs:
The City of Jeffersonville currently has employees that are bilingual in English and Spanish who are
available and willing to translate requests from the Hispanic population.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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SUMMARY OF LEP ACCOMMODATION PLAN
• The City of Jeffersonville strives to serve its population to the best of its ability and will provide
upon request, services to assist the LEP population including translation of vital documents and
interpretation services deemed necessary to provide meaningful access to City services.
• A U.S. Census Bureau I Speak card is available as part of this document. This card allows LEP
individuals to communicate their preferred language to City Staff whereas City Staff may then
access a translation service as determined by the City.
• The City of Jeffersonville utilizes a voluntary public involvement survey to collect information
regarding persons affected by proposed projects. The survey permits respondents to remain
anonymous, while voluntarily answering questions regarding their gender, ethnicity, race, age,
sex, disability status, and household income. Once the survey data has been collected, it will be
reviewed and then the survey will be placed in a file for future reference. In the case enough
surveys are collected over time to show a significant increase in LEP populations, the City may
consider changes to their LEP policy. Completed surveys shall be retained for a period of three
years from the date of the meeting and/or completion of the related project, if applicable.
• The City reviews written Title VI complaints and ensures every effort is made to resolve
complaints informally at the local or regional level and review and update the City's Title VI plan
and procedures as required.
• Staff for the City will be provided training on the requirements for providing meaningful access
to services for LEP persons and new employees will receive the same training.
TITLE VI TRAINING
EMPLOYER/EMPLOYEE DISSEMINATION & TRAINING
At the time of Hire (and annually to all employees if applicable): Title VI policy education and
literature will be provided to all City of Jeffersonville employees. City of Jeffersonville employees will
be required to sign an acknowledgement of receipt indicating they have received and reviewed Title VI
policy guidelines. New employees will be provided with education and literature at new employee
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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orientation. Employees will be provided with updated education and literature as City of Jeffersonville
deems necessary.
Ongoing Training provided to current employees: Current employees will receive training annually if
applicable. Training will consist of education and literature and will be in person to the employee or a
new hire. Employees will be required to sign an acknowledgement receipt indicating they have received
and reviewed Title VI policy guidelines. Employees will receive updated education and literature as
deemed necessary.
Employees will be expected to follow the Title VI policy and the guidelines set forth. In addition, City of
Jeffersonville employees should make every effort to alleviate any barriers to service or public use that
would restrict public access or usage, take prompt and reasonable action to avoid or minimize
discrimination incidences and immediately notify the Title VI Coordinator, in writing, of any questions,
complaints or allegations of discrimination.
PUBLIC INVOLVEMENT
DATA COLLECTION
Pursuant to 23 CFR 200.9(b) (4), City of Jeffersonville shall collect and analyze statistical information
regarding demographics to assist in monitoring and ensuring nondiscrimination in all of its programs
and activities.
City of Jeffersonville shall utilize a voluntary Title VI public involvement survey that will be available at
all public hearings and meetings. The survey will allow respondents to remain anonymous. The survey
will ask questions regarding the respondent's gender, ethnicity, race, age, income and if they are
disabled. The facilitator of the public hearings and meetings will make an announcement at the
beginning of the meeting informing attendees of the survey and its purpose and a request will be made
for the attendees to complete the voluntary survey.
Completed surveys will be retained by the Title VI Coordinator for three (3) years.
The Title VI Coordinator will also collect and report statistical data for the past three (3) years as it
relates to the number of federally funded projects, complaints filed and the results of those complaints,
any requests for language services, demographic statistics and department compliance reviews.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 2024-2025
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COMMUNITY INVOLVEMENT & OUTREACH
City of Jeffersonville is committed to ensuring that community involvement and outreach is done in a
respectful and appropriate manner that will allow for diverse involvement. Public meetings, programs
and activities will provide equitable opportunities for participation.
The City of Jeffersonville host meetings monthly and those meetings are open to the public. Any
meetings that are open to the public are published on City of Jeffersonville website's main page. All
City of Jeffersonville public meetings are held in locations accessible to individuals with disabilities.
Upon request, translators can be provided free of charge to those individuals with limited English
proficiency. Auxiliary aids are also available upon request. Requests must be made within forty-eight
(48) hours in advance.
Also published on the City of Jeffersonville website are various meeting agenda's, meeting minutes,
notices, events and news. Some departments within City of Jeffersonville utilize signage, media and
social media websites as another avenue to communicate with the community.
REVIEW OF PROGRAM AREA
This section outlines annual goals set forth by City of Jeffersonville to comply with Title VI requirements
and statutes. This list will be monitored for updates and additions.
ANNUAL WORK PLAN
[Identify program areas/ policies prioritized for review of potential disparate impacts and / or
discriminatory outcomes here and include an explanation of why/ how this program area / policy
was identified for review. (See Subrecipient Technical Assistance Toolkit provided to you with this
sample document for further explanation of programmatic implementation of Title VI and Goals/
Accomplishment Reporting)]
Accomplishments I Completion Date
INPUT ACCOMPLISHMENTS HERE INPUT COMPLETION DATE HERE
Submitted ADA Title VI Transition Plan October 2024
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Goals Target Completion Date
INPUT GOALS HERE INPUT TARGET COMPLETION DATE HERE
Place ADA &Title VI Documents on website March 2025
Develop process for annual Title VI Goals & September 2025
Accomplishments Report
Develop & Implement complaint procedure September 2025
Develop ADA &Title VI Training for City September 2025
Employees
Develop process to ensure assurances are December 2025
being used in all federal contracts
Submit annual goals & accomplishments December 2025
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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APPENDIX
A. Assurances
B. Complaint Policy
B-1 Complaint Form/Release
C. Complaint Log
D. External Complaint Procedure
D-1 External Complaint Form
E. Voluntary Involvement Survey
F. I-Speak Cards
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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APPENDIX A: ASSURANCES
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Title VI Assurances
The City of Jeffersonville(hereinafter referred to as the"Recipient")HEREBY AGREES THAT as a condition to receiving
any Federal financial assistance from the Department of Transportation and the Federal Highway Administration, it will
comply with Title VI of the Civil Rights Act of 1964, 78 Stat. 252,42 U.S.C. 2000d-42 U.S.C. 2000d-4 (hereinafter referred
to as the Act), and all requirements imposed by or pursuant to Title 49, Code of Federal Regulations (CFR), Department of
Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination in Federally-Assisted Programs of the
Department of Transportation-Effectuation of Title VI of the Civil Rights Act of 1964,Title 23 Code of Federal Regulations,
Part 200, Title VI Program and Related Statutes — Implementation and Review Procedures (hereinafter referred to as the
Regulations) and other pertinent nondiscrimination authorities and directives, to the end that in accordance with the Act,
Regulations, and other pertinent nondiscrimination authorities and directives, no person in the United States shall, on the
grounds of religion, race color, or national origin, sex (23 USC 324), sexual orientation, gender identity (Executive Order
13672), age (42 USC 6101), disability/handicap (29 USC 790) and low income (Executive Order 12898) be excluded from
participation in,be denied the benefits of,or be otherwise subjected to discrimination under any program or activity for which
the Recipient receives Federal financial assistance from the Department of Transportation, including the Federal Highway
Administration, and HEREBY GIVES ASSURANCE THAT it will promptly take any measures necessary to effectuate this
agreement. This assurance is required by Title 49 Code of Federal Regulations, subsection 21.7(a)(1) and Title 23 Code of
Federal Regulations,section 200.9(a)(1)of the Regulations,copies of which are attached.
More specifically and without limiting the above general assurance, the Recipient hereby gives the following specific
assurances with respect to its Federal Aid Highway Program.
1. That the Recipient agrees that each"program" and each"facility as defined in 49 CFR subsections 21.23(e) and (b) and
23 CFR 200.5(k)and(g)of the Regulations,will be(with regard to a"program")conducted,or will be(with regard to a
"facility")operated in compliance with all requirements imposed by,or pursuant to,the Regulations.
2. That the Recipient shall insert the following notification in all solicitations for bids for work or material subject to the
Regulations and made in connection with all Federal-Aid Highway Programs and, in adapted form in all proposals for
negotiated agreements:
The Indiana Department of Transportation(INDOT),in accordance with Title VI of the Civil Rights Act of 1964,78 Stat.
252, 42 U.S.0 2000d to 2000d-4 and Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A,
Office the Secretary,Part 21,Nondiscrimination in Federally assisted programs of the Department of Transportation and
Title 23 Code of Federal Regulations, Part 200, Title VI Program and Related Statutes, issued pursuant to such Acts,
hereby notifies all bidders that it will affirmatively insure that in any contact entered into pursuant to this advertisement,
disadvantaged business enterprises will be afforded full opportunity to submit bids in response to this invitation and will
not be discriminated against on the grounds of religion, race, color, national origin, sex, sexual orientation, gender
identity,age,disability/handicap and low income in consideration for an award.
3. That the Recipient shall insert the clauses of Appendix A of this assurance in every contract subject to the Acts and the
Regulations.
4. That the Recipient shall insert the clauses of Appendix B of this assurance, 'as a covenant running with the land, in any
deed from the United States effecting a transfer of real property,structures,or improvements thereon,or interest therein.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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5. That where the Recipient receives Federal fmancial assistance to construct a facility, or part of a facility, the assurance
shall extend to the entire facility and facilities operated in connection therewith.
6. That where the Recipient receives Federal fmancial assistance in the form, or for the acquisition of real property or an
interest in real property,the assurance shall extend to rights to space on,over or under such property.
7. That the Recipient shall include the appropriate clauses set forth in Appendix C of this assurance, as a covenant running
with the land, in any future deeds, leases, permits, licenses, and similar agreements entered into by the Recipient with
other parties: (a) for the subsequent transfer of real property acquired or improved under the Federal-Aid Highway
Program; and(b) for the construction or use of or access to space on, over or under real property acquired, or improved
under the Federal-Aid Highway Program.
8. That this assurance obligates the Recipient for the period during which Federal fmancial assistance is extended to the
program, except where the Federal financial assistance is to provide, or is in the form of, personal property, or real
property or interest therein or structures or improvements thereon,in which case the assurance obligates the Recipient or
any transferee for the longer of the following periods: (a) the period during which the property is used for a purpose for
which the Federal fmancial assistance is extended, or for another purpose involving the provision of similar services or
benefits;or(b)the period during which the Recipient retains ownership or possession of the property.
9. The Recipient shall provide for such methods of administration for the program as are found by the Secretary of
Transportation or the official to whom he delegates specific authority to give reasonable guarantee that it,other recipients,
subgrantees, contractors, subcontractors, transferees, successors in interest, and other participants of Federal financial
assistance under such program will comply with all requirements imposed or pursuant to the Act,the Regulations and this
assurance.
10. The Recipient agrees that the United States has a right to seek judicial enforcement with regard to any matter arising
under the Act,the Regulations,and this assurance.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans,contracts,
property, discounts or other Federal fmancial assistance extended after the date hereof to the Recipient Department of
Transportation under the Federal-Aid Highway Program and is binding on it, other recipients, subgrantees, contractors,
subcontractors, transferees, '(i censors in interest and other participants in the Federal-Aid Highway Program. The person or
persons whose signatures a, ar below are a thorized to sign this assurance on behalf of the Recipient
Signature Date
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
19
APPENDIX A-1
During the performance of this contract,the contractor,for itself, its assignees and successors in interest(hereinafter referred
to as the"contractor")agrees as follows:
(1) Compliance with Regulations: The contractor shall comply with the Regulation relative to nondiscrimination in
Federally-assisted programs of the Department of Transportation (hereinafter, "DOT") Title 49, Code of Federal
Regulations, Part 21, and the Federal Highway Administration (hereinafter "FHWA") Title 23, Code of Federal
Regulations, Part 200 as they may be amended from time to time, (hereinafter referred to as the Regulations), which are
herein incorporated by reference and made a part of this contract.
(2) Nondiscrimination: The Contractor,with regard to the work performed by it during the contract, shall not discriminate
on the grounds of religion, race, color, national origin, sex, sexual orientation, gender identity, age, disability/handicap
and low income in the selection and retention of subcontractors, including procurements of materials and leases of
equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by 49 CFR,
section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in
Appendix B of the Regulations.
(3) Solicitations for Subcontractors,Including Procurements of Materials and Equipment: In all solicitations either by
competitive bidding or negotiation made by the contractor for work to be performed under a subcontract, including
procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the
contractor of the contractor's obligations under this contract and the Regulations relative to nondiscrimination on the
grounds of religion, race, color,national origin, sex, sexual orientation, gender identity, age, disability/handicap and low
income.
(4) Information and Reports: The contractor shall provide all information and reports required by the Regulations or
directives issued pursuant thereto, and shall permit access to its books, records, accounts, other sources of information,
and its facilities as may be determined by the Indiana Department of Transportation (INDOT) or the FHWA to be
pertinent to ascertain compliance with such Regulations, orders and instructions. Where any information required of a
contractor is in the exclusive possession of another who fails or refuses to furnish this information the contractor shall so
certify to INDOT or the FHWA as appropriate,and shall set forth what efforts it has made to obtain the information.
(5) Sanctions for Noncompliance: In the event of the contractor's noncompliance with the nondiscrimination provisions of
this contract,INDOT shall impose such contract sanctions as it or the FHWA may determine to be appropriate,including,
but not limited to:
(a.) withholding of payments to the contractor under the contract until the contractor complies,and/or
(b.) cancellation,termination or suspension of the contract,in whole or in part.
(6) Incorporation of Provisions: The contractor shall include the provisions of paragraphs (1) through (6) in every
subcontract,including procurements of materials and leases of equipment,unless exempt by the Regulations,or directives
issued pursuant thereto.
The contractor shall take such action with respect to any subcontract or procurement as INDOT or the FHWA may direct as a
means of enforcing such provisions including sanctions for non-compliance:Provided,however,that, in the event a contractor
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
20
becomes involved in, or is threatened with, litigation with a subcontractor or supplier as a result of such direction, the
contractor may request the Indiana Department of Transportation to enter into such litigation to protect the interests of the
Indiana Department of Transportation and, in addition, the contractor may request the United States to enter into such
litigation to protect the interests of the United States.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
21
APPENDIX A-2
A.The following clauses shall he included in any and all deeds effecting or recording the transfer of real property, structures
or improvements thereon,or interest therein from the United States.
(GRANTING CLAUSE)
NOW, THEREFORE, the Department of Transportation, as authorized by law, and upon the condition that the Indiana
Department of Transportation will accept title to the lands and maintain the project constructed thereon, in accordance with
Title 23,United states Code of Federal Regulations,the Regulations for the Administration of Federal-Aid Highway Programs
and the policies and procedures prescribed by FHWA, also in accordance with and in compliance with all requirements
imposed by or pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the
Secretary, Part 21,Nondiscrimination in Federally-assisted programs of the Department of Transportation and Title 23 Code
of Federal Regulations,Part 200,Title VI Program and Related Statutes(hereinafter referred to as the Regulations)pertaining
to and effectuating the provisions of Title VI of the Civil Rights Act of 1964 (78 Stat. 252; 42 U.S.C. .2000d to 2000d-4),
does hereby remise, release, quitclaim and convey unto the Indiana Department of Transportation all the right, title and
interest of the Department of Transportation in and to said lands described in Exhibit "A" attached hereto and made a part
hereof.
(HABENDUM CLAUSE)
TO HAVE AND TO HOLD said lands and interests therein unto the Indiana Department of Transportation and its successors
forever, subject, however, to the covenants, conditions, restrictions and reservations herein contained as follows, which will
remain in effect for the period during which the real property or structures are used for a purpose for which Federal financial
assistance is extended or for another purpose involving the provision of similar services or benefits and shall be binding on the
Indiana Department of Transportation its successors and assigns.
The Indiana Department of Transportation, in consideration of the conveyance of said lands and interests in lands, does
hereby covenant and agree as a covenant running with the land for itself,its successors and assigns,that(1)no person shall on
the grounds of religion, race, color,national origin, sex, sexual orientation, gender identity, age, disability/handicap and low
income be excluded from participation in,be denied the benefits of,or be otherwise subjected to discrimination with regard to
any facility located wholly or in part on over or under such lands hereby conveyed [,] [and)* (2)that the Indiana Department
of Transportation shall use the lands and interests in lands and interests in lands so conveyed,in compliance with all require-
ments imposed by or pursuant to Title 49,Code of Federal Regulations,Department of Transportation, Subtitle A,Office of-
the Secretary,Part 21,Nondiscrimination in Federally-assisted programs of the Department of Transportation-Effectuation of
Reverter clause and related language to be used only when it is determined that such a clause is necessary in order to effectuate the
purposes of Title VI of the Civil Rights Act of 1964.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Title VI of the Civil Rights Act of 1964, Title 23 Code of Federal Regulations, Part 200, Title VI Program and Related
Statutes—Implementation and Review Procedures, and as said Regulations may be amended [,] and(3) that in the event of
breach of any of the above-mentioned nondiscrimination conditions, the Department shall have a right to re-enter said lands
and facilities on said land, and the above described land and facilities shall thereon revert to and vest in and become the
absolute property of the Department of Transportation and its assigns as such interest existed prior to this instruction.*
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
23
APPENDIX A-3
The following clauses shall be included in all deeds, licenses, leases, permits, or similar instruments entered into by the
Indiana Department of Transportation(INDOT)pursuant to the provisions of Assurance 7(a).
The (grantee, licensee, lessee, permitee, etc., as appropriate) for himself, his heirs, personal representatives, successors in
interest,and assigns,as a part of the consideration hereof,does hereby covenant and agree[in the case of deeds and leases add
"as a covenant running with the land"] that in the event facilities are constructed, maintained, or otherwise operated on the
said property described in this (deed, license, lease, permit, etc.) for a purpose for which a Department of Transportation
program or activity is extended or for another purpose involving the provision of similar services or benefits, the (grantee,
licensee, lessee, permitee, etc.) shall maintain and operate such facilities and services in compliance with all other
requirements imposed pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A,office of
the Secretary,Part 21,Nondiscrimination in Federally-assisted programs of the Department of-Transportation-Effectuation of
Title VI of the Civil Rights Act of 1964, Title 23 Code of Federal Regulations, Part 200, Title VI Program and Related
Statutes—Implementation and Review Procedures,and as said Regulations may be amended.
[Include in licenses,leases,permits,etc.]*
That in the event of breach of any of the above nondiscrimination covenants, INDOT shall have the right to terminate the
[license, lease, permit, etc.] and to re-enter and repossess said land and the facilities thereon, and hold the same as if said
[licenses,lease,permit,etc.]had never been made or issued.
[Include in deed.]*
That in the event of breach of any of the above nondiscrimination covenants,Indiana Department of Transportation shall have
the right to re-enter said lands and facilities thereon,and the above described lands and facilities shall thereupon revert to and
vest in and become the absolute property of INDOT and its assigns.
The following shall be included in all deeds, licenses, leases,permits,or similar agreements entered into by INDOT pursuant
to the provisions of Assurance 7(b).
The (grantee, licensee, lessee, permitee, etc., as appropriate) for himself, his personal representatives, successors in interest,
and assigns, as a part of the consideration hereof,does hereby covenant and agree(in the case of deeds, and leases add "as a
Reverter clause and related language to be used only when it is determined that such a clause is necessary in order to effectuate the
purposes of Title VI of the Civil Rights Act of 1964.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
24
covenant running with the land") that (1) no person on the ground of religion, race, color, national origin, sex, sexual
orientation, gender identity, age, disability/handicap and low income shall be excluded from participation in, denied the
benefits of, or he otherwise subjected to discrimination in the use of said facilities, (2) that in the construction of any
improvements on, over or under such land and the furnishing of services thereon, no person on the ground of religion, race,
color,national origin,sex,sexual orientation,gender identity,age,disability/handicap and low income,shall be excluded from
participation in, denied the benefits of,or otherwise be subjected to discrimination,(3)that the(grantee,licensee,lessee,per-
mitee, etc.) shall use the premises in compliance with all other requirements imposed by or pursuant to Title 49, Code of
Federal Regulations. Department of Transportation, Subtitle A, Office of the Secretary. Part 21, Nondiscrimination in
Federally-assisted programs of the Department of Transportation-Effectuation of Title VI of the Civil Rights Act of 1964),
Title 23 Code of Federal Regulations, Part 200, Title VI Program and Related Statutes — Implementation and Review
Procedures,and as said Regulations may be amended.
[Include in licenses,leases,permits,etc.]*
That in the event of breach of any of the above nondiscrimination covenants, INDOT shall have the right to terminate the
[license, lease, permit, etc.] and to re-enter and repossess said land and the facilities thereon, and hold the same as if said
[license,lease,permit,etc.]had never been made or issued.
[Include in deeds]`
That in the event of breach of any of the above nondiscrimination covenants,INDOT shall have the right to re-enter said land
and facilities thereon, and the above described lands and facilities shall thereupon revert to and vest in and become the
absolute property of INDOT and its assigns.
•Reverter clause and related language to be used only when it is determined that such a clause is necessary in order to effectuate the
purposes of Title VI of the Civil Rights Act of 1964.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
25
APPENDIX B: COMPLAINT POLICY
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN ( 2024-2025
26
Complaint Policy
Any person who believes that he or she as a member of a protected class,has been discriminated against based on
race,color,national origin,gender,age,disability,religion,low income status,or Limited English Proficiency in
violation of Title VI of the Civil Rights Act of 1964,as amended and its related statutes,regulations and
directives, Section 504 of the Vocational Rehabilitation Act of 1973,Americans with Disabilities Act of 1990,as
amended,the Civil Rights Restoration Act of 1987,as amended, and any other Federal nondiscrimination statute
may submit a complaint.A complaint may also be submitted by a representative on behalf of such a person.
It is the policy of the City of Jeffersonville to conduct a prompt and impartial investigation of all allegations of
discrimination and to take prompt effective corrective action when a claim of discrimination is substantiated.
No one may intimidate,threaten,coerce or engage in other discriminatory conduct against anyone because they
have taken action or participated in an action to secure rights protected by the civil rights laws.Any individual
alleging such harassment or intimidation may submit a complaint by following the procedure printed below.
Any individual who feels that he or she has been discriminated against may submit a written or verbal complaint.
The complaint may be communicated to any company supervisor or to the company EEO Officer.The complaint
should be submitted within 180 days of the alleged discrimination.Complaint forms may be found [INDICATE
WHERE COMPLAINTS FORMS MAY BE FOUND].Individuals are not required to use the company's
complaint form. If necessary,the company will help an individual reduce his or her complaint to writing for his or
her signature.
Generally a complaint should include the name,address and telephone number of the individual complaining
(complainant)and a brief description of the alleged discriminatory conduct including the date of harm.An
individual submitting a complaint alleging discrimination may include any relevant evidence,including the names
of witnesses and supporting documentation.
Complaints should be directed to:
ANDY CROUCH,TITLE VI COORDINATOR
500 QUARTERMASTER CT.
812-285-6476
FAX 812-280-4703
ACROUCH(ii CITYOFJEFF.NET
Within 60 days of the receipt of the complaint the company will conduct an investigation of the allegation based
on the information provided and issue a written report of its fmdings to the complainant.The company will try to
obtain an informal voluntary resolution to all complaints at the lowest level possible.
A complainant's identity shall be kept confidential except to the extent necessary to conduct an investigation.All
complaints shall be kept confidential.
These procedures do not deny the right of any individual to file a formal complaint with any government agency or
affect an individual's right to seek private counsel for any complaint alleging discrimination.
Complaints may also be filed with the following government agencies:
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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Indiana Department of Transportation
Economic Opportunity Division
100 N. Senate,Room N750
Indianapolis, IN 46204
Phone: (317) 233-6511
Fax: (317)233-0891
Indianapolis District EEOC Office
101 West Ohio Street, Ste 1900
Indianapolis, IN 46204
Phone: (800) 669-4000
Fax: (317)226-7953
TTY: 1 (800)669-6820
Indiana Civil Rights Commission
100 N. Senate Ave., Room N103
Indianapolis, IN 46204
Toll Free: 1 (800) 628-2909
Phone: (317)232-2600
Fax: (317)232-6560
Hearing Impaired: 1 (800) 743-3336
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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APPENDIX B-1: COMPLAINT FORM/RELEASE
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
29
CITY OF JEFFERSONVILLE TITLE VI COMPLAINT FORM
Title VI of the Civil Rights Act of 1964 states that"No person in the United States shall on the grounds of race,
color,or national origin, be excluded from participation in, be denied the benefit of,or otherwise be subjected
to discrimination in any program, service,or activity receiving federal assistance."
This form may be used to file a complaint with CITY OF JEFFERSONVILLE based on violations of Title VI of the
Civil Rights Act of 1964.You are not required to use this form; a letter that provides the same information
may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged
discrimination. If you could not reasonably be expected to know the act was discriminatory within 180-day
period,you have 60 days after you became aware to file your complaint.
If you need assistance completing this form, please contact the Title VI/Non-Discrimination Coordinator, by
phone at(812) 285-6476 or via e-mail at acrouch@cityofjeff.net.
Name: Date:
Street Address:
City: State: Zip Code:
Telephone: (home) (work) (other)
Individual(s) discriminated against, if different than above (use additional pages, if needed).
Name: Date:
Street Address:
City: State: Zip Code: _
Telephone: (home) (work) (other)
Please explain your relationship with the individual(s) indicated above:
Name of agency and department or program that discriminated:
Agency or department name:
Name of individual (if known):
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
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CITY OF JEFFERSONVILLE TITLE VI COMPLAINT FORM
(CONTINUED) Date(s)of alleged discrimination:
Date discrimination began Last or most recent date
ALLEGED DISCRIMINATION: If your complaint is in regard to discrimination in the delivery of services or
discrimination that involved the treatment of you by others by the agency or department indicated above,
please indicate below the basis on which you believe these discriminatory actions were taken.
Race Color Religion National Origin Age Sex
Disability Income Other (please specify)
Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in
the alleged discrimination (attach additional sheets, if necessary, and provide a copy of written material
pertaining to your case).
Signature:
Please return completed form to: Title VI/Non-Discrimination Coordinator
500 Quartermaster Ct.
Jeffersonville, IN 47130
Phone: 812-285-7476
E-mail: acrouch@cityofjeff.net
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
31
Note:City of Jeffersonville prohibits retaliation or intimidation against anyone because that individual has either taken action or
participated in action to secure rights protected by policies of the City.Please inform the person listed above if you feel you were
intimidated or experience perceived retaliation in relation to filing this complaint.
CITY OF JEFFERSONVILLE I TITLE VI IMPLMENTATION PLAN 12024-2025
32
COMPLAINANT CONSENT/RELEASE FORM
Name(first,middle,last) Telephone number
( )
Address(number and street,city,state,ZIP code)
Case number(s)(if known)
As a complainant, I understand that during an investigation it may become necessary for City of Jeffersonville to
reveal my identity to individuals outside of City of Jeffersonville Government in the course of verifying information
or gathering facts and evidence to develop a basis for making a civil rights compliance determination. I understand
that it may be necessary for City of Jeffersonville to share information, including personal details collected as part
of its complaint investigation. In addition, I understand that as a complainant, I am protected by Title VI of the
Civil Rights Act of 1964, as amended, and its related statutes and regulations prohibiting intimidation or
retaliation for taking action or participating in an action to secure rights protected by the nondiscrimination
statutes enforced by City of Jeffersonville.
Please read both paragraphs below, check your choice of CONSENT or CONSENT DENIED and sign below.
(Please mark one)
CONSENT
I have read and understand the above information and authorize City of Jeffersonville to disclose my identity
to individuals as needed during the course of the investigation for the purpose of verifying information or gathering
facts and evidence relevant to the investigation of my complaint. I authorize City of Jeffersonville to receive,
review, and discuss material and information about me relevant to the investigation of my complaint. I understand
that the material and information will be used for authorized civil rights compliance and enforcement activities.
I further understand that I am not required to authorize this release and volunteer to do so.
CONSENT DENIED
I have read and understand the above information and do not want City of Jeffersonville to disclose my identity
to any individual during the course of the investigation. I understand this choice could delay the investigation
of my complaint and may, in some circumstances, result in an administrative closure of the investigation of
my complaint without City of Jeffersonville making a determination in my case.
Signature Date(month,day,year)
APPENDIX C: COMPLAINT LOG
34
TITLE VI COMPLAINT LOG
Case No. Investigator Complainant Sub- Protected Date Filed Date of Deposition
recipient Category Final
Report
35
APPENDIX D: EXTERNAL COMPLAINT PROCEDURE
36
EXTERNAL COMPLAINT OF DISCRIMINATION
INSTRUCTIONS:
The purpose of this form is to help any person interested in filing a discrimination complaint with the
City of Jeffersonville.You are not required to use this form.You may write a letter with the same
information, sign it, and return it to the address below.All bold items must be completed for your
complaint to be investigated.Failure to provide complete information may impair the investigation of
your complaint.
Title VI of the Civil Rights Act of 1964,as amended and its related statutes and regulations(Title VI)
prohibit discrimination on the basis of race,color,national origin, sex,age, disability/handicap,or income
status in connection with programs or activities receiving federal financial assistance for the United States
Department of Transportation,Federal Highway Administration,and/or Federal Transit Administration.
These prohibitions extend to the City of Jeffersonville as a sub-recipient of federal financial assistance.
Upon request,assistance will be provided if you are an individual with a disability or have limited
English proficiency. Complaints may also be filed using alternative formats such as computer disk,
audiotape,or Braille.You also have the right to file a complaint with other state or federal agencies that provide federal
financial assistance to the City of Jeffersonville.Additionally,you have the right to seek private counsel.
The City of Jeffersonville is prohibited from retaliating against any individual because he or she opposed
an unlawful policy or practice, filed charges,testified,or participated in any complaint action under Title
VI or other nondiscrimination authorities.
Please make a copy of your complaint form for your personal records.Do not send your original
documents as they will not be returned.Mail the original complaint form along with any copies of
documents or records relevant to your complaint to the address below.
Complaints of discrimination must be filed within 180 days of the date of the alleged discriminatory act.
If the alleged act of discrimination occurred more than 180 days ago,please explain your delay in filing
this complaint.
**Your complaint cannot be processed without your signature.
37
APPENDIX D-1: EXTERNAL COMPLAINT FORM
38
COMPLAINANT INFORMATION
Name(first,middle,and last)
Address(number and street,city,state and ZIP code)
Home telephone number Work telephone number Cellular telephone number
t ) ( )
Name of complainant Date(month,day,year)
PERSON I AGENCY YOU BELIEVE DISCRIMINATED AGAINST YOU
Name(first,middle,and last) Title
Name of company
Address(number and street,city,state and ZIP code)
Home telephone number Work telephone number Celular telephone number
) ( )
When was the last alleged discriminatory act?(month,day,year)
Complaints of discrimination must be filed within 180 days of the date of the alleged discriminatory act. If the alleged act of
discrimination occurred more than 180 days ago,please explain your delay in filing this complaint.
The alleged discrimination was based on:
❑ Race ❑ Color ❑ Gender ❑ National Origin ❑ Disability ❑ Age ❑ Retaliation
Describe the alleged act(s)of discrimination. (Use additional pages, if necessary.)
39
Name of complainant Date(month,day,year)
Provide the names of any individuals with additional information regarding your complaint:
Name of witness 1(first,middle,and last) Title
Name of company
Address(number and street,city,state and ZIP code)
Home telephone number Work telephone number Cellular teiephone number
)
Include a brief description of the relevant information the witness may provide to support your complaint of discrimination.
Name of witness 2(first,middle,and last) Title
Name of company
Address(number and street,city,state and ZIP code)
Home telephone number Work telephone number Cellular telephone number
-
Include a brief description of the relevant information the witness may provide to support your complaint of discrimination.
Name of witness 3(first,middle,and last) Title
Name of company
Address(number and street,city,state and ZIP code)
Home telephone number Work telephone number Cellular telephone number
)
}
Include a brief description of the relevant information the witness may provide to support your complaint of discrimination.
How would you like your complaint to be resolved?
40
Name of complainant Date(month,day,year)
Have you filed a complaint alleging the same discrimination with another state or federal agency? ❑ Yes ❑ No
If yes,please provide the following information for each agency:
Name of the agency Date complaint filed(month,day,year)
Case number assigned to your complaint Current status of your complaint
How did you learn about your right to file a discrimination complaint with INDOT?
Signature Date signed(month,day,year)
41
APPENDIX E: VOLUNTARY PUBLIC INVOLVEMENT SURVEY
42
VOLUNTARY TITLE VI PUBLIC INVOLVEMENT SURVEY
As a recipient of federal funds,the Indiana Department of Transportation(INDOT)is requiring local
agencies to develop a procedure for gathering statistical data regarding participants and beneficiaries of its
federal-aid highway programs and activities(23 CRF§200.9(b)(4)).The City of Jeffersonville is distributing
this voluntary survey to fulfill that requirement to gather information about the populations affected by
proposed projects.
You are not required to complete this survey.Submittal of this information is voluntary.This form is a public
document that the City of Jeffersonville will use to monitor its programs and activities for compliance with
Title VI and the Civil Rights Act of 1964,as amended and its related statutes and regulations.
If you have any questions regarding the(Name of LPA)'s responsibilities under Title VI of the Civil Rights
Act of 1964 or the Americans with Disabilities Act,please contact(Name),Title VI Coordinator,(Address),
(City,State,Zip),(Email address).
You may return the survey by folding it and placing it on the registration table or by mailing or e-mailing it
to the address below.
Date:
Project Name:
Proposed Project Location:
Gender:■ Female■ Male Ethnicity: ■Hispanic or Latino ■ Not Hispanic or Latino
Race: (Check one or more
■ American Indiana or Alaska Native El Asian
. Native Hawaiian or Other Pacific Islander . White
■ Black or African-American ■ Multiracial
Age: Disability:
■ 1-21 IN 22-40 ■ Yes
III 41-65 65+ 1. No
Household Income:
. $0-$12,000 $12,001-$24,000 ■ $24,001-$36,000
111 $36,001-$48,000 111 $48,001-$60,000 ■ $60,001+
43
Andy Crouch,Title VI Coordinator
500 Quartermaster Ct.
Jeffersonville,IN 47130
812-285-6476
acrouch@cityofjeff.net
44
APPENDIX F: I-Speak Cards
45
2004
Census 2010
Test LANGUAGE IDENTIFICATION FI.ASHCARD
El
,..,,,,.14 1i.f:. 1. Arabic
iwastrour
❑ mr Our 1r�na �.r c ems. �. 2. Armenian
❑ xlgt wortr arov °RW ItaR vx tzar at ITIF fi't RF I 3. Bengali
❑ g111111rrtlii tbitli tttE: tt tittgl8 t1DttfttJtilAf1 fit 9 4. Cambodian
❑ Mntka i kahhnn ya yangin Qrtiingnu manaitai pet fintingnu kutnentos Chamorro 5. Chamorro
❑ 6. Simplified
Chinese
❑ P1l �lit8a�A • 1t 7.Traditional
Chinese
Omacrtc oval kvadratic ako citatc ili govotitc hrvatski Jezik 8.Croatian
❑ Zatkrtnctc tuto kolonku,pokud ctete a ho afitc ccsky. 9. Czech
❑ Krum dit vak aan als u Nederland% kunt kzen of sprekcn 10 Dutch
❑ Mark this box if you read or speak English 11 English
❑ -41;t • Xr 14&tea 4. 1i • I 12. Farsi
?3 3i' O 5 DEPARTMENT OF COM.ER(E
Loam..r Stab tirr•..sa
U t CMOs tiAE.0
Cochcr ici si vas livez ou pakz k francas. 13. French
Krcuzcn Sic dicscs Kast:hcn an.wcnn Sic Deutsch kscn odcr sprcchcn. 14. German
F �cvcti COnd so naakno av a kat3grce?i iukdzs Waivnc4. 15. Greek
16. Haitian
!sl.il.c ►J!\: W l ,I +,u li , ,.. .. Ixrl-, Zits d .c.i,•,cn Creole
arrt aria fit ant* Tr!'trq verk t,t} atint TrK 1 17. Hindi
El
Kts. tub voi no'vs koj path twin thiab hats lus Hmoob. 18. Hrnong
kloljc mcg czt a kockit,ha mcgcrti vagy bcsaIi amagyarnychct 19. Hungarian
❑ Markaan daytoy nga kahon no makabasa wcnm makasaoka m Dos:lulu 20. llocano
Marchi qucsta casclla se kggc o parta itahano. 21. Italian
E ir,&L). icktedeat;tiZtealti t<& 61Q 22. Japanese
V-101 11- Si 7i itifi R,l°Vi 01 41 23. Korean
0
irrivintkhntranrio. 24. Laotian
ElPtt my o zana3enic ego kuadrau.lcftli pnstuguxc se Pi..f'u 25. Polish
vkicm polskim
i
us oalw1►E1rr of caarelcE
Gee ti frb yMfi
U I®1!U$11.11EM1
47
Acsinak cste quadrsdn sc voc2 k ou Pala!x)rtugucs 26. Portuguese
insemnt i acxud as*daddttp sm vartc151mninerk. 27. Romanian
❑ nOMC 61C .ntn kNap4).11 .CC.us H61 t I:YC to ►.IH IOHopifn• ito-pyivax. 28. Russian
El
06eamure amaj nimparsidi puma=mum mug mm. 29. Serbian
El
Ornate tento stvortck,ak vlctc cltat akbo Evurit pu sloscnsky. 30. Slovak
El
Marque cstacasi1La si kc o habla cspainl 31. Spanish
Matkahan itong kuw•adrado kung kayo ay marur/ong magbasa o magsalita ag Tagalog. 32.Tagalog
larrnnlarbannpattvnat nl-nachutltoipuxnrilm. 33.Thai
Maaka'i he puha ni kapau 'oku kc Lau pc Ica takatanga. 34.Tongan
tiii iinrc qo K:ar i.y. w uaj aN'NTaETe a6o rosopwre yKpaiNchacio weak). 35. Ukranian
_{,,c. 4A;--A►i/J71. r' 36. Urdu
Xin danh d5u vao 6 nay neu quy vi hic't doe va ntii dttcfe \'i t NgCt. 37.Vietnamese
.rnr Cr n-writ o we aro 5+ooyp oort tna•3130 38.Yiddish
oeMalaENT OF COMMENCE
ua.01MMMIS NUEaI