SAMPLE – SAMPLE ‐ SAMPLE

This sample worksheet was developed by collecting commendable practices from Federal Highway Administration rec

provided by FHWA as an example of how state highway agencies, as well as cities, counties, and metropolitan planning o

and catalog all Title VI‐related data sources to help ensure compliance with Title VI of the Civil Rights Act of 1964. It is 

exhaustive list of possible data sources or as the only acceptable format for capturing this data. FHWA recipients can and 

collection instruments to suit their particular needs.
Contracts and Finance

Data/Information Description Collection Personnel Data Contact Internal System / Resource External Source 

Construction Contracts ‐ Provisions [Contracts Specialist] [Contracts Specialist]

Electronic Project File on [internal shared drive] None. 

Inwinco

Construction Contracts ‐ Bidding [Contracts Specialist] [Contracts Specialist]

Advertisement Records and Construction Manual None. 

Inwincoan

Construction Contracts ‐Prequalification [Contracts Specialist]

[Prequalification Department Official] [Prequalification Database] None. 

Dap

Professional Services Contracts ‐Provisions [Contracts Specialist] [Procurement Official]

Electronic Project File on [internal shared drive] None. 

Inwinco

Professional Services Contracts ‐Bidding [Contracts Specialist] [Procurement Official]

Advertisement Records and Procurement Manual None. 

Inwincoan

Professional Services Contracts ‐Selection and Award [Contracts Specialist] [Procurement Official]

Form 145 (Proposal Scoresheet), Proposal Records, Bidders List None. 

DaseDcoDo

U.S. Census ‐ 5 Year  to

Contract Amounts [Finance Specialist] [Finance Specialist] [Internal Database] ACS, 2010 Census M
Planning

Data/Information Description Collection Personnel Data Contact Internal System / Resource External Source 

Public Involvement ‐ STIP Development Meetings [Planning Specialist]

Communications Data Team

[Internal Database] ‐Communications None.

DpS

Public Involvement ‐ STIP Development Meeting Attendee Demographics [Planning Specialist]

Communications Data Team

[Internal Database] ‐Communications

Form 1234: completed by attendees

Dada

Public Involvement ‐ Text of Formal Comments submitted during STIP development process [Planning Specialist] [Planning Specialist]

Electronic Project File on [internal shared drive]

Email, website submissions

Innp

Public Involvement ‐ Text of Informal Comments submitted during STIP development process [Planning Specialist] [Planning Specialist]

Electronic Project File on [internal shared drive]

Oral comments noted by Communications staff at meeting. 

Innp

Public Involvement ‐ Civil Rights Personnel Meeting Attendance [Title VI Coordinator] [Title VI Coordinator]

[Internal spreadsheet] on [internal shared drive] None.

Innr

Project Prioritization ‐ Scoring data for prioritization reviewers [Planning Specialist] [Planning Specialist]

Scoring sheets and [database] managed by Planning Division

Some scoring sheets collected from regional/local partners

Dat

Project Prioritization ‐ distribution of projects statewide [Planning Specialist] [Planning Specialist]

[Internal spreadsheet] on [internal shared drive]

U.S. Census ‐ 5 Year ACS, 2010 Census; TIP data where necessary

DddM

Certification Reviews ‐ Policy Reviews and recommendations  [Title VI Coordinator] [Title VI Coordinator]

[Civil Rights Division Certification Files]

MPO Title VI, LEP, TIP, and Long‐Range Plans

InrdInsdd
Environment

Data/Information Description Collection Personnel Data Contact

Internal System / 

Resource External Source 

Daatt

Public Involvement ‐ Project Area  Communications Data  [Internal Database] ‐ U.S. Census ‐ 5 Year  de

Demographics [Environmental Specialist] Team Communications ACS, 2010 Census pro

Public Involvement ‐ Meeting Attendee Demographics

[Communications Specialist]

Communications Data Team

[Internal Database] ‐Communications

Form 1234: completed by attendees

Daattdepro

Public Involvement ‐ Text of Formal Comments [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive]

Email, website submissions

Infnopa

Public Involvement ‐ Text of Informal Comments [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive]

Oral comments noted by Communications staff at meeting. 

Infnopa

Public Involvement ‐ Civil Rights Personnel Meeting Attendance [Title VI Coordinator] [Title VI Coordinator]

[Internal spreadsheet] on [internal shared drive] None.

InfnurigInfpoalt

Project Scoping [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive]

U.S. Census ‐ 5 Year ACS, 2010 Census

deaff

Environmental Review ‐ Number of Categorical Exclusions [Environmental Specialist]

[Environmental Specialist]

[Internal spreadsheet] on [internal shared drive] None. 

Dacat

Environmental Review ‐ Number of Environmental Assessments [Environmental Specialist]

[Environmental Specialist]

[Internal spreadsheet] on [internal shared drive] None. 

DaEn

Environmental Review ‐ Number of Environmental Impact Statements [Environmental Specialist]

[Environmental Specialist]

[Internal spreadsheet] on [internal shared drive] None.

DaEn
Environmental Review ‐ Number of 

Community Impact Assessments [Planning Specialist] [Planning Specialist]

[Internal spreadsheet] on [internal shared drive] None.

DaCo

Environmental Review ‐Demographics of Project/Study Area [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive]

U.S. Census ‐ 5 Year ACS, 2010 Census

Daco

Environmental Review ‐ Air Quality Impacts for Each Alternative [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive] Air Quality Report

Daalt

Environmental Review ‐ Noise Impacts for Each Alternative [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive] Noise Impact Report

Daalt

Environmental Review ‐ Right of Way Impacts [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive]

Right of Way Form 1235 (relocatee profile)

Daderelalt

Environmental Review ‐ Mitigation Measures [Environmental Specialist]

[Environmental Specialist]

Electronic Project File on [internal shared drive] None.

Quto ad
Right of Way

Data/Information Description Collection Personnel Data Contact

Internal System / 

Resource External Source 

Public Involvement ‐ Right of Way Project meetings [Right of Way Specialist]

Communications Data Team

[Internal Database] ‐Communications

Form 1234: completed by attendees

Daattdeaff

Relocation ‐ Appraisal Data [Right of Way Specialist]

[Right of Way Specialist]

Electronic Project File on [internal shared drive]

Right of Way Form 1235 (relocatee profile), Appraisal Log and Recommendation

Daof Co

Relocation ‐ Assistance Data [Right of Way Specialist]

[Right of Way Specialist]

Electronic Project File on [internal shared drive]

Right of Way Form 1235 (relocatee profile), relocation assistance contractor files

Daasspaincrel

Consultants [Right of Way Specialist]

[Right of Way Specialist]

Contracts Division database None. 

DaassadWaIncapow
Construction

Data/Information Description Collection Personnel Data Contact Internal System / Resource External Source 

Construction Contracts ‐ Mitigation Commitments [Contracts Specialist] [Project Engineer]

Project log (dailies), change orders, EIS/EA, contract provisions None. 

Inwcemt

Contstruction Contracts ‐ Traffic Control [Contracts Specialist] [Project Engineer]

Traffic Control Plan, Project Log (dailies), EA/EIS 

U.S. Census ‐ 5 Year ACS, 2010 Census

Datpd

Construction Contracts ‐ Pedestrian Accommodation [Contracts Specialist] [Project Engineer]

Traffic Control Plan, Project Log (dailies), EA/EIS 

U.S. Census ‐ 5 Year ACS, 2010 Census

Datpd