VA Form 20-8734a Supplement to Equal Opportunity Compliance Review Report

OMB Approved No. 2900-0456
Respondent Burden: 45 minutes

SUPPLEMENT TO EQUAL OPPORTUNITY COMPLIANCE REVIEW REPORT
PRIVACY ACT INFORMATION: The information requested in this report is required by law (Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of
1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Executive Order 12250). Failure to report may result in withdrawal of Federal
financial assistance. Your obligation to respond is required inorder to obtain or retain benefits. The information solicited may be disclosed outside the Department of Veterans
Affairs only if the disclosure is authorized under the Privacy Act.
RESPONDENT BURDEN: We need this information to assure thatVA Federally -funded programs are in compliance with equal opportunity laws. We estimate that you will
need an average of 45 minutes to review the instructions, find the information and complete the form. VA cannot conduct or sponsor, and respondent is not required to
respond to this collection of information unless a valid OMB control number is displayed.You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

NOTE: If additional space is needed for an explanation, record item number(s) and comment(s) in Item 28, Remarks, or on a continuation sheet.
1. NAME AND ADDRESS OF FACILITY

2. DATE OF REVIEW

SECTION I - PARTICIPANT INTERVIEW
3A. NAME OF PARTICIPANT (First, middle, last)

3C. NATIONAL ORIGIN

3D. SEX

3B. RACE

3E. AGE

4. TYPE OF HANDICAP (If applicable)

NOTE - An asterisk (*) indicates that corrective action(s) may be required. If this block is checked, provide an
explanation in Item 28, Remarks.

5. TENURE

YES

NO

*

6. ARE FACILITY PROGRAMS ACCESSIBLE TO HANDICAPPED PARTICIPANTS?
7. DOES THE FACILITY PROVIDE HOUSING FOR PROGRAM PARTICIPANTS?

8. IS FACILITY HOUSING ACCESSIBLE AND CONVENIENT FOR HANDICAPPED PARTICIPANTS?

*

9. IF THE FACILITY PROVIDES SEPARATE HOUSING FOR HANDICAPPED PARTICIPANTS, IS IT COMPARABLE TO HOUSING PROVIDED
FOR
NONHANDICAPPED PARTICIPANTS?

*

10. ARE THERE SEPARATE OR SPECIAL SERVICES PROVIDED FOR PARTICIPANTS BASED ON RACE, COLOR, NATIONAL ORIGIN, SEX,
HANDICAP, OR AGE?

*

11. IS THE TRAINING PROVIDED EQUAL FOR ALL PARTICIPANTS REGARDLESS OF RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP,
OR AGE?
12. ARE THERE ANY MODIFICATIONS IN PROGRAM REQUIREMENTS FOR HANDICAPPED PARTICIPANTS?

*
*

13. ARE HANDICAPPED PARTICIPANTS PERMITTED TO TAKE PART IN ALL REGULAR CLASSROOM ACTIVITIES?

*

14. ARE THE EDUCATIONAL SETTINGS PROVIDED FOR HANDICAPPED PARTICIPANTS COMPARABLE TO REGULAR CLASSROOMS AND
TRAINING AREAS?

*

15. ARE THERE PROGRAMS AND ACTIVITIES SPONSORED BY THE FACILITY THAT ESTABLISH AN AGE DISTINCTION?

*

16. DOES THE PARTICIPANT TAKE PART IN FACILITY SPONSORED EXTRACURRICULAR SERVICES AND ACTIVITIES REGARDLESS OF
RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP, OR AGE?

*

17. IN THE PARTICIPANT’S OPINION, ARE FACILITY COUNSELING, FINANCIAL, AND EMPLOYMENT ASSISTANCE
PROGRAMS AVAILABLE TO ALL PARTICIPANTS ON A NONDISCRIMINATORY BASIS?

*

18. IS PARTICIPANT AWARE OF FACILITY’S JOB PLACEMENT ASSISTANCE?
19. IN PARTICIPANT’S OPINION, DO ALL PARTICIPANTS GET FULL BENEFITS FROM JOB PLACEMENT PROGRAMS REGARDLESS OF
RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP, OR AGE?

*

20. IN PARTICIPANT’S OPINION, ARE ALL PARTICIPANTS INFORMED OF EMPLOYMENT RECRUITING ACTIVITIES AND GIVEN AN
OPPORTUNITY TO BE INTERVIEWED BY RECRUITERS?

*

21. DOES THE PARTICIPANT HAVE PROBLEMS WHICH ARE BASED ON RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP, OR AGE?
22A. IN PARTICIPANT’S OPINION, WERE ADMISSION REQUIREMENTS INCLUDING TESTS, RELEVANT TO CURRICULUM AND TRAINING
APPLIED FOR?
22B. IN PARTICIPANT’S OPINION, ARE ALL PARTICIPANTS TREATED EQUALLY IN ALL ASPECTS OF THE PROGRAM REGARDLESS OF
RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP, OR AGE?
VA FORM
EXISTING STOCK OF VA FORM 20-8734a, MAR 1998,
JUL 2007
WILL BE USED.

20-8734a

*
*
*

N/A

SECTION II - INSTRUCTOR INTERVIEW
23A. NAME OF TRAINER/INSTRUCTOR

23C. NATIONAL ORIGIN

23B. RACE

23D. SEX

23E. AGE

23F. TYPE OF HANDICAP (If applicable)

NOTE - An asterisk (*) indicates that corrective action(s) may be required. If this block is checked, provide an
explanation in Item 28, Remarks.
25. IS THE INSTRUCTOR AWARE OF ANY DISCRIMINATORY ACTIONS BY THE FACILITY IN ITS TREATMENT OF PARTICIPANTS OR
EMPLOYEES ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, HANDICAP, OR AGE?

24. TENURE

YES

NO

*

26. ARE CLASSES AND TRAINING PROGRAMS INTEGRATED?

*

27A. ARE HANDICAPPED PARTICIPANTS PERMITTED TO TAKE PART IN ALL TRAINING/CLASSROOM ACTIVITIES?

*

27B. ARE HANDICAPPED PARTICIPANTS SEGREGATED FROM NON-HANDICAPPED PARTICIPANTS?
27C. WHEN HANDICAPPED PARTICIPANTS ARE NOT PERMITTED TO TAKE PART IN ALL TRAINING/CLASSROOM ACTIVITIES, ARE
COMPARABLE CLASSROOM ENVIRONMENTS PROVIDED FOR HANDICAPPED PARTICIPANTS?

*
*

28. REMARKS

29A. SIGNATURE OF PARTICIPANT/INSTRUCTOR

29B DATE SIGNED

N/A