Form FS-1700-0006A Civil Rights Compliance Review Record-Federally Assisted

Civil Rights Compliance Review Record Federally Assisted Programs

FS-1700-0006A (REV. 08/2012)
OMB 0596-0215 (EXP. 11/2011)

(Ref. FSH 1709.11) Internal Use Only

This form is for recording reviews of recipients of Federal Financial Assistance. Response is mandatory to retain or obtain benefits. This
form provides the requirements for conducting a Civil Rights Compliance Review 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 Equal Opportunity 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 receiving financial assistance from 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 Civil Rights 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. It is necessary for the Forest Service to separate the CR
Compliance Review form to protect the privacy of any individuals who agree to be interviewed during the post-award review. If the
recipient requests a copy of the full review record, only the FS-1700-0006A record will be provided.
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. Response to this information collection is mandatory to retain or obtain benefits The valid OMB
control number for this information collection is 0596-0215. 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 RECIPIENT INFORMATION
It is necessary for the Forest Service to separate the CR Compliance Review form to ensure the privacy of any individuals who agree to
be interviewed for the review. Form FS-1700-0006A serves as a comprehensive pre-award and post-award review record for recipients.
The CR Review Forms will be kept with the recipient's file. However, if the recipient requests a copy of the full review record, only the FS1700-0006A record will be provided.

1. FS Unit Name:

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

2. Program or Activity Title:
3. Special Uses Code:

OR Grant Number:

4. Business / Organization Name:
Business / Organization Phone Number: ( )

-

AND / OR Applicant / Recipient Last Name:
Phone Number: ( )

Applicant / Recipient First Name:

-

5. Applicant or Recipient Address Line 1:
Applicant or Recipient Address Line 2:
Applicant or Recipient City:

State:

Zip Code:

Applicant or Recipient EMail:
6. Today's Review Date:
Filecode: 1770

/ /

7. Previous Review Date:

/ /
Page 1 of 5

FS-1700-0006A (REV. 08/2012)
OMB 0596-0215 (EXP. 11/2011)

PART II - PRE-AWARD AND POST-AWARD CHECKLIST
Indicate by checking one

Pre-Award Review

Post-Award Review

REVIEWER RESPONSES
Yes

No

N/A

If explanations are provided, enter in Part III.
1. Has the Forest Service explained the civil rights responsibilities for nondiscrimination in
federally assisted program delivery to the recipient and provided the program delivery brochure,
required nondiscrimination poster, and information on the program complaint process?
2. Does the recipient’s permit, agreement, or grant contain the appropriate clause assuring
compliance with civil rights laws and statutes under program delivery (Title VI and related EO
laws)?
APPLICANT/RECIPIENT RESPONSES

Yes

No

N/A

If explanations are provided, enter in Part II.
3. Will / Do your applicable publications, informational materials (including computer-based) and
signs contain a statement of affiliation with the FS?
4. Will / Do the publications (e.g., brochures, advertisements) and other informational materials
(including computer-based) you use contain the USDA nondiscrimination statement?
5. Will / Do you communicate to customers how to file a complaint with USDA? (Describe in
Part IV – Additional Information, below)
6. Will / Do promotional illustrations depict individuals representing diversity, i.e., race, color,
national origin, sex, age, persons with disabilities?
7. Will / Is the And Justice for All poster (Form AD-475C) (be) in a visible location for program
participants/customers and employees?
8. a. Are any of your program/project informational materials needed by your customers in
languages other than English? If so, what actions have you taken to address this?
b. Do you take reasonable steps to ensure that persons with limited English proficiency
receive the language assistance necessary (free of charge) for your programs and activities?
9. 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?
10. 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, color, national origin, sex, age, and
disability) eligible to be served?
b. Do you then use this information in planning your outreach strategies?
11. 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
12. a. Have you explained the civil rights and nondiscrimination responsibilities to your
employees?
b. Have you explained the above responsibilities to your sub-recipients?
13. Is (Are) your program(s) fully accessible to persons with disabilities? If no, explain in Part IV
– Additional Information
14. 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

Filecode: 1770

Page 2 of 5

FS-1700-0006A (REV. 08/2012)
OMB 0596-0215 (EXP. 11/2011)

PART III - SUMMARIES
ADDITIONAL INFORMATION
Use this section to describe or explain in more detail your answers to specific questions in Part II or Part IV.

Identify any deficiencies and/or barriers. Below, indicate actions to be taken by the Holder or Recipient/Applicant and
the Forest Service to correct any deficiencies and/or barriers identified as a result of this review.

Reviewer Last Name: __________________________________ Reviewer First Name:_________________________________
Reviewer Signature: __________________________________________ Title: _______________________________________
/ /
Date: _______________
Filecode: 1770

Page 3 of 5

FS-1700-0006A (REV. 08/2012)
OMB 0596-0215 (EXP. 11/2011)

PART IV - RECORD OF SELF-EVALUATION FOR ACCESSIBILITY
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.
Special Uses Code:

Grant Number:

Business Name:
Applicant/Recipient Last Name:
Applicant/Recipient First Name:
Yes

No

Phone Number:

( )

-

N/A
QUESTIONS:
1. 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.

2. Do you review policies, practices, and procedures to ensure that none contains
language that excludes qualified persons with disabilities from services?
3. Do you offer assistance, when appropriate, in filling out forms to qualified persons
with disabilities?
4. Do you notify associations of/persons with disabilities of your services through public
outreach efforts?
5. 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?
6. Do you ensure access to persons with mobility limitations or other impairments, if
transportation services provided?
7. 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?
8.a. Do you provide qualified sign-language interpreter services, if such services are
requested?
8.b. Are audio-visual presentations and multimedia captioned? Are computer–based
products, produced as a result of this project/partnership, accessible?
9. Do you ensure that all new and newly renovated buildings and facilities comply with
appropriate accessibility standards or have waivers to requirements?
10. Do you ensure that facilities for services have an emergency egress plan?
Reviewer Last Name:

Reviewer First Name:

Reviewer Signature: __________________________________________ Title: _______________________________________
/ /
Date: ______________

Filecode: 1770

Page 4 of 5

FS-1700-0006A (REV. 08/2012)
OMB 0596-0215 (EXP. 11/2011)

INSTRUCTIONS

Part I - FS and Recipient Information
Complete:
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 provide the grant number (if this review
involves an applicant/recipient of a grant or agreement)
4. Provide the business/organization name; provide the recipient/applicant's (owner/manager) name, telephone number,
5. Provide the full address and e-mail.
6. Provide the current compliance review date
7. If the Forest Service previously reviewed the program or activity, provide the date.

Part II - Pre-Award and Post-Award Checklist
- Answer the first two questions under the "Reviewer Response"
- Questions 3-14: Ask the applicant/recipient questions 3-14 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 III - Summaries" to record the recipient/applicant's explanation and narrative description and/or describe the
rationale for a negative response and as a supplement to a response to any question asked in "Part II."
Part III - 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, and IV, and to summarize
any deficiencies and/or barriers, and plans for corrective actions.
Part IV - Self-Evaluation for Accessibility
- Answer question 1
Ask the recipient if they have conducted the self-evaluation (Section 504 of the Rehabilitation Act of 1973), which certifies the
completion of a self-evaluation of their policies and practices for accessibility to persons with disabilities, within one year after
receiving a permit, cooperative agreement or domestic grant. 7CFR15b.8(C ) Verify the 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.
-For question 8a. - Verify if partners are aware of and will use qualified American Sign Language Interpreter Services if
requested.
- For question 8b. - If the recipient is developing multimedia and computer based products (websites, databases) as a result of
the project/partnership, require accessibility (captioning) and compliance with the Rehabilitation Act of 1973, as amended.
File the record (with original signature) along with FS-1700-0006B and FS-1700-0006C in the Forest Service recipient's case file.
If the Recipient requests a copy of the full review record in FS-1700-0006, only the recipient response FS-1700-0006A will be
provided.

Filecode: 1770

Page 5 of 5