Form FS-1700-6 Equal Opportunity Program Delivery Compliance Review Rec

USDA Forest Service FS-1700-6 (7/2008)

OMB 0596-New

Equal Opportunity Program Delivery Compliance Review Record

(Ref FSH 1709.11)

Internal Use Only

This form is for recording reviews of recipients of Federal Financial Assistance. This form provides the requirements for conducting Equal Opportunity (EO) Program Delivery Compliance Reviews and is for INTERNAL use only. The purpose is to record: (a) the Reviewer’s observations and information concerning a recipient’s program or activity, and (b) the responses to questions listed in this review to gauge the recipient’s level of compliance with Civil Rights laws, rules, and regulations, and policies while verifying the recipient’s assurance certification to comply with Department Regulation 4330-2 and 7 CFR Subtitle A, Part 15 – Nondiscrimination, Subparts A and B.

Compliance in EO Program Delivery includes ensuring that no one is denied an equal opportunity to participate in, receive benefits from, and receive access to any program or service funded by the Federal government. Program delivery, nondiscrimination compliance applies to both federally conducted programs (i.e. conducted directly by Federal agencies) and federally assisted programs (i.e., administered through a recipient/Special Use Permit holder). Program delivery compliance for federally assisted programs and activities falls under the following Civil Rights Acts: Title VI of the Civil Rights Act of 1964, as amended; Section 504 of the Rehabilitation Act of 1973; Title IX of the Education Amendments of 1973; and the Age Discrimination Act of 1975, as amended.

The Forest Service reviewer should complete the EO Program Delivery Compliance Record by working with each individual applicant or recipient whose program or activity has been designated for review to determine the level of compliance with Civil Rights laws, as well as Federal regulations and policy. File the completed form in the applicant or recipient’s case file. Give only a copy of Part V to the applicant and/or recipient, as a documented record of the Self-Assessment of Accessibility.

For purposes of this form, an “applicant” refers to a person, organization, or other entity applying for a permit, domestic grant, or cooperative agreement for Federal financial assistance. A “recipient” refers to any recipient of Federal financial assistance or funding, i.e. a partner receiving a grant or agreement, or holder of a Special Use Authorization (specifically a public service provider).

Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-New. The time required to complete this information collection is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

Part I – Forest Service and Recipient Information

FS Unit Name:

     

(e.g., Region/Station/Area/Forest/ District/Laboratory)

Program or Activity Title:

     

Special Uses Code:

     

Grant Number/Case Code:

     

Business/Organization Name:

     

Applicant or Recipient Name:

     

Phone Number:

     

Address and e-Mail:

     

Today’s Review Date:

     

Last Review Date:

     

Part II – Pre-Award and Post-Award Checklist 
Indicate by checking one
Pre-Award Review				Post-Award Review
Yes 	No 	N/A 	If explanations are provided, enter in Section IV.
Reviewer Responses:
			Has the Forest Service explained the civil rights responsibilities for nondiscrimination in program delivery to the recipient and provided the program delivery brochure, required nondiscrimination poster, and information on the program complaint process?
			Does the recipient’s permit, agreement, or grant contain the appropriate clause certifying compliance with civil rights laws and statutes under program delivery (Title VI and related EO laws)?
Applicant/Recipient Responses:
			Do your applicable publications, informational materials (including computer-based) and signs contain a statement of affiliation with the FS?
			Do the publications (e.g., brochures, advertisements) and other informational materials you use contain the USDA nondiscrimination statement?
			Do you communicate to customers how to file a complaint with USDA? (Describe in Part IV – Additional Information, below)
			Do promotional illustrations depict individuals representing diversity, i.e. ethnicity, race, color, national origin, sex, age, persons with disabilities?
			Is the And Justice for All poster (Form AD-475C) in a visible location for program participants/customers and employees?
			Are any of your program/project informational materials provided to your customers in languages other than English? If so, provide/attach example(s).
			Do you gather voluntary information regarding the race, color, national origin, sex, age, and disability on the proposed and present membership of planning or advisory boards/councils to ensure diversity representation?
			a. Before conducting outreach activities for your program or project, do you refer to census data or other information to identify the population (by race, national origin, sex, age, and disability) eligible to be served?
			b. Do you then use this information in planning your outreach strategies?
			Have any customers raised issues alleging discrimination or filed discrimination complaints against your program(s) in the past 2 years? If yes, describe in Part IV – Additional Information (below)
			Have you explained the civil rights and nondiscrimination responsibilities to your employees? Have you explained the above expectations to your sub-recipients?
			Are your program(s) and facilities fully accessible to persons with disabilities? If no, explain in Part IV – Additional Information (below)
			a. Are there any architectural barriers to your facilities preventing full accessibility to your program(s) by participants?
			b. If yes, was an action/transition plan created to remove barrier(s) and maintained in your files? Describe progress in Part IV, Additional Information (below)

Part III – Additional Questions for Post-Award Reviews
Yes 	No 	N/A 
Interview a Program participant/beneficiary:
			Have you experienced any difficulty accessing program information or participating in the services offered by the service provider?
			Have you experienced or observed any discriminatory behavior by the service provider and/or employees? If so, describe the behavior in the space provided below.
			Description of behavior:      
			Name of Customer (Optional):      
Interview an Employee of the Recipient:
			Have you been trained or informed of your responsibilities under civil rights laws about nondiscrimination?
			Have you received information on how to advise participants/customers on filing a program discrimination complaint?
			Description of training, guidance, etc.:      
			Name of Employee (Optional):      

Part IV – Summaries
Additional Information Use this section to describe or explain in more detail your answers to specific questions in Part 1 and Part II above.
     
     
     
     
Summary Identify any deficiencies and/or barriers. Below, indicate actions to be taken by the Holder or Recipient and the Forest Service to correct any deficiencies and/or barriers identified as a result of this review.
     
     
     
     
REVIEWER (please print):		     				Date:      
Signature:				Title:	     

Note: The applicant and recipient should retain a copy of the following section (Part V). The Forest Service will retain the original in the applicant’s and/or recipient’s case file or record.

Part V – Record of Self-Evaluation for Accessibility

Special Uses Code:

     

Grant Number/Case Code:

     

Business Name:

     

Applicant or Recipient Name:

     

Phone Number:

     

Yes 

No 

N/A 

Questions:

Did you conduct a “Self-Evaluation of Accessibility” according to Section 504 of the Rehabilitation Act of 1973, within one year after receiving a permit, agreement, or grant? If you answered NO to this question, answer the questions below to determine your level of compliance with accessibility requirements for your program or activity.

Do you review policies, practices, and procedures to ensure that none contains language that excludes qualified persons with disabilities from services?

Do you offer assistance, when appropriate, in filling out forms to qualified persons with disabilities?

Do you notify associations of/persons with disabilities of your services through public outreach efforts?

Do you allow persons with disabilities to take an application home (upon request) to be completed, because the person’s disability precludes completion on site?

Do you ensure access to persons with mobility limitations or other impairments, if transportation services provided?

Do you provide auxiliary aids and services to qualified persons with disabilities, e.g., large print menus or material, pen and paper at ticket sales offices?

Do you provide qualified sign-language interpreter services, if such services are requested? Are audio-visual presentations and videos (closed) captioned? Are computer–based products accessible?

Do you ensure that all new and newly renovated buildings and facilities comply with appropriate accessibility standards or have waivers to requirements?

Do you ensure that facilities for services have an emergency egress plan?

REVIEWER (please print):

     

Date:

Signature:

Title:

     

Instructions

Part I – FS and Recipient Information

Questions

1. Provide the Forest Service Unit name, e.g. Region/Forest/Ranger District/Station/Laboratory

2. List the type of program or activity being reviewed

3. Provide the Use Code (if this review involves a Special Uses authorization) or

4. Provide the grant number or case code (if this review involves an applicant/recipient of a grant or agreement)

5. Provide the business/organization name

6. Provide the recipient/applicant’s (owner/manager) name, telephone number, address and e-mail address.

7. Provide the current compliance review date

8. Provide the date the program or activity was last reviewed by the Forest Service

Part II – Pre-Award and Post-Award Checklist

• Answer the first two questions under the “Reviewer Response”

• Questions 1-14: Ask the applicant/recipient questions 1-14 in Part II (note question 9 does not apply to Special Use permits), record answer to each question (include additional narratives as indicated).

• Use “Part IV – Summaries” to record the recipient/applicant’s explanation and/or describe rationale for negative response to the question.

• Add the recipient/applicant’s explanation or narrative description to “Part IV – Summaries” as a supplement to a response to any question asked in “Part II”

Part III – Additional Questions for Post-Award Reviews

Note: This section does not apply to applicants. Only complete for recipients.

• When possible, schedule employee interviews in advance of the onsite post-award compliance review and conduct interviews during the review of recipient’s employees. Conduct interviews with program participants as appropriate.

• Ask the questions and, as appropriate, use Part IV to record both participant and employee interview responses.

Part IV – Summaries for Pre-Award and Post-Award Reviews

• Use this section to describe or explain the applicant/recipient’s answers to questions in Parts I, II, III, and V, and to summarize any deficiencies and/or barriers, and plans for corrective actions.

Part V – Self-Evaluation for Accessibility

• Answer question 1

Ask the recipient (only those with 15 or more employees) if they have conducted the self-evaluation (Section 504 of the Rehabilitation Act of 1973), which certifies accessibility compliance with their activity or program/project within one year after receiving a permit, cooperative agreement, or domestic grant. (7CFR15b.8 (g)) Verify date and describe in Section IV Additional Information.

If the answer is no, then ask questions 2-10 in this section and evaluate responses to determine if level of accessibility compliance is acceptable.

• File the record (with original signature), along with Parts I-IV of this form, in the recipient’s case file.

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