SAMPLE – SAMPLE ‐ SAMPLE 

This sample flyer for the collection of demographic data was developed by collecting commendable 

practices from Federal Highway Administration recipient agencies. It is provided by FHWA as an example 

of how state highway agencies, as well as cities, counties, and metropolitan planning organizations, can 

collect demographic information at public meetings to help ensure compliance with Title VI of the Civil 

Rights Act of 1964. It is not intended as an exhaustive list of possible demographic categories or as the

only acceptable format for capturing this data. FHWA recipients can and should tailor their data 

collection instruments to suit their particular needs.  
 

 

 

 

Demographic informaƟon: 

Please fill out the informaƟon below. This will help us to ensure that we are reaching the 

communiƟes that are effected by our projects and planning. If you have quesƟons or need assistance 

please see an MDOT employee, or call 1-555-555-5555. Thank you. 

What categories best describe you? 

Mark all boxes that apply AND print ethnicities in the spaces below. 

Note, you may report more than one group. 

□ White 

□ German □ Irish □ English 

□ Italian □ Polish □ French 

Print, for example, Scotttish, Norweigan, etc. 

□ Black or African American □ Middle Eastern or North African 

□ African American □ Jamaican □ Haitian □ Lebanese □ Iranian □ Egyptian 

□ Nigerian □ Ethiopian □ Somali □ Syrian □ Moroccan □ Algerian 

Print, for example, Ghanian, South African, Barbadian, etc. Print, for example, Israeli, Iraqi, Tunisian, etc. 

□ Asian 

□ Chinese □ Filipino □ Asian Indian 

□ Vietnamese □ Korean □ Japanese 

Print, for example, Pakistani, Cambodian, Hmong, etc. 

□ Native Hawaiian or Other Pacific Islander 

□ Native Hawaiian □ Samoan □ Fijian 

□ Chamorro □ Tongan □ Marshallese 

Print, for example, Palauan, Tahitian, Chuukese, etc. 

Do you speak a language other than English? 

□ Spanish □ French □ Arabic 

□ Chinese □ Tagalog □ Korean 

Do you consider yourself to have a disability? 

□ Yes For assistance with reasonable accomadations, plese call 555-555-5555 

□ No 

Block for information in other languages 

□ Hispanic, Latino, or Spanish 

□ Mexican or Mexican America □ Puerto Rican 

□ Cuban □ Dominican □ Salvadoran 

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc. 

□ American Indian or Alaska Native 

Print, for example, Navajo, Blackfeet Tribe, Mayan, Aztec, etc. 

□ Some Other Race or Ethnicity 

Print details 

Age: 

□ Under 18 □ 18 -40 

□ 41 - 65 □ 65+ 

Block for other language / miscellaneous 
MyState JONES ROAD OVER SMITHFIELD PARKWAY BRIDGE REHABILITATION PROJECT Department of TransportaƟon 

WELCOME TO THE PUBLIC MEETING! 

Included with this card is a short survey for you to tell us a liƩle bit more 

informaƟon about yourself. You may fill out and turn in it at the welcome table or, 

if you choose, drop it in the mail to send it back to us. Thank you! 

JONES ROAD OVER 

SMITHFIELD PARKWAY 

QUESTIONS OR ASSISTANCE? 

John Dixon 

Equal Opportunity Manager 

email: Jdixon@mystate.gov 

phone: 555-555-5555 

U.S. Postage Paid 

MyState Department of TransporaƟon 

c/o Equal Opportunity Manager 

5555 Michaels St. 

Capital City, My State 10001