Form FS-1700-0006C Civil Rights Compliance Review Record -Federally Assiste

Civil Rights Compliance Review Record Federally Assisted Programs, Participant Interview
(Ref. FSH 1709.11) Internal Use Only

FS-1700-0006C (REV. xx/xxxx)
OMB# 0596-NEW (EXP. XX/XX/XX)

During a Post-award review, this form is to be used as a continuation of the Civil Rights Compliance Review Record - Federally
Assisted Programs. This section will record a response from a Program Participant of the Recipient only. It is necessary for
the Forest Service to separate the CR Compliance Review Record forms to protect the privacy of any individuals who agree to
be interviewed during the post-award review. If the Recipient requested a copy of the full review record in FS-1700-0006, this
participant response - FS-1700-0006C will not be included.
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 voluntary. The valid OMB control number for this
information collection is 0596-NEW. The time required to complete this information collection is estimated to average 5 minutes 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 POST AWARD REVIEW INTERVIEW OF A PARTICIPANT
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-1700-0006C serves as a post award review record for participants of the
recipient's program or activities. The CR Review Forms A, B, C, will be kept with the Forest Service recipient's file. However,
if the recipient requests a copy of the review, the form FS-1700-0006C is not to be provided.
Yes

No

N/A
1. Have you experienced any difficulty accessing program information or participating in
the services offered by the service provider?
2. 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.
PART II SUMMARIES
Use this section to provide more detail to the answers to specific questions.

Filecode: 1770

Page 1 of 2

FS-1700-0006C (REV. xx/xxxx)
OMB# 0596-NEW (EXP. XX/XXXX)

INSTRUCTIONS

Part I - Additional Questions for Post-Award Reviews
Note: This section does not apply to applicants. Only complete during a Post-Award Review.
- When possible, ask program participants or beneficiaries if they are willing to answer questions regarding the services they
have received from the recipients. Ask the questions and use Part II to record the participant's interview responses.
Part II - Summaries for Post-Award Reviews
- Use this section to describe or explain the answers to the Part I. questions made by participants or beneficiaries of the
recipient's program, and to summarize any deficiencies and/or barriers.
File the record along with FS-1700-0006A and FS-1700-0006B in the recipient's case file. If the Recipient requested a copy of
the full review record in FS-1700-0006, this participant response - FS-1700-0006C will not be included.

Filecode: 1770

Page 2 of 2