Form GSA XXXX GSA XXXX Nondiscrimination in Federal Financial Assistance Compli

Nondiscrimination in Federal Financial Assistance OMB Control Number:

XXXX-XXXX
Expiration Date: XX/XX/20XX

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Compliance Questionnaire for Real Property Recipients

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of
the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget (OMB) control number. The OMB control number for this collection is 3090-0310. We estimate that it will take 120 minutes to read
the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for
reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat
Division (MVCB), 1800 F Street, NW, Washington, DC 20405.

This compliance questionnaire is used in conjunction with the Federal Real Property Public Benefit Conveyance program.
This program is a Federal financial assistance program administered by the U.S. General Services Administration (GSA), a
Federal Agency. As a recipient of surplus Federal real property, you are required to be compliant with Federal
nondiscrimination laws. Those laws are the following: Title VI of the Civil Rights Act of 1964, as amended; Age
Discrimination Act of 1975; Section 504 of the Rehabilitation Act of 1973, as amended; Title IX of the Education
Amendments Act of 1972; and Federal Property Management Act of 1949, as amended.

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Generally, the aforementioned laws provide that no person in the United States shall, on the ground of race, color, national
origin, sex, disability, or age, be subject to discrimination under any program or activity receiving Federal financial assistance.
Federal agencies that provide financial assistance are responsible for ensuring that recipients of Federal assistance operate
their programs and activities in a nondiscriminatory manner. Thus, GSA's implementing and enforcement regulations for
these laws are located under the Code of Federal Regulations (CFR) at 41 CFR 101-4 et. seq; 41 CFR 101-6.2 et. seq; 41
CFR 101-8.3 et. seq; and 41 CFR 101-8.7 et. seq. Pursuant to these laws and regulations, your organization must keep
records and submit compliance reports to GSA for the purpose of determining your organization's compliance.
Your organization's responses to this questionnaire will be used by the GSA's Office of Civil Rights (OCR) to help determine if
your organization is in compliance with these laws and regulations. In order to analyze this information, OCR personnel will
have access to this information. OCR will retain this information for four (4) years from the time of receipt.
Organization ID Number:
Street Address:

City:

Organization Name:

A
State:

ZIP Code:

Submitted by:
Name:

Title:

Email:

Telephone:

Fax:

Preparation Date:

I. Organizational Background:

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A. Please describe the nature and purpose of your agency/organization, to include programs and activities conducted by
your agency/organization.

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GENERAL SERVICES ADMINISTRATION

GSA XXXX XX/20XX

B. Please mark one or more of the following categories that best describes the "organizational type" for your agency/
organization:
State Government Agency

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County or City Government Agency
Non-profit Organization
Healthcare-related provider
Educational provider
Provider to the Homeless or Impoverished
Minority-focused
Women-focused
Program for Older Individuals
Individuals with Disabilities-focused
Other (If Other, please explain in the space below)

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II. Civil Rights Data

A

[NOTE: For all questions regarding race or ethnicity reporting, first, report the race, (i.e., American Indian/Alaska Native,
Asian, Black/African American, Native Hawaiian/Other Pacific Islander, and White); then report ethnicity (i.e., Hispanic or
Non-Hispanic).]
A. Please provide the current composition (based on race, ethnicity, and sex) of any advisory board, committee,
etc. that has influence and/or control over the way in which your federally assisted programs and/or activities are
administered:
RACE

ETHNICITY

American Indian or Alaska Native

Hispanic or Latino

Asian

Non-Hispanic or Non-Latino

Black or African American
Native Hawaiian or Other Pacific Islander
White
Number of Total Board Members

F

SEX
Male
Female

B. Individuals who, because of their national origin, are Limited English Proficient (LEP) are entitled to meaningful
access to federally assisted programs and activities. (See GSA's LEP guidance for recipients of Federal financial
assistance at https://www.gsa.gov/civilrights) Does your agency/organization's service area population include
individuals with Limited English Proficiency?

Yes
No

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C. If so, what are the languages most encountered? (Please mark all that apply)
Spanish
Chinese

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Vietnamese
Korean
Other (If Other, please explain in the space below)
N/A

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D. Where non-English languages are encountered, what type(s) of translation or interpretation assistance services
does your agency/organization provide to LEP individuals? (Please mark all that apply)
Bilingual Staff
Contract Interpreter/Translator
Translated Written Materials
Volunteers
Local Community-Based Organization
Local College/University Language Department
State Agency that provides this service
Other (If Other, please explain in the space below)

A

N/A

F

E. How does your agency/organization notify its LEP population regarding the availability of LEP assistance?
Please describe all methods used.
Posting a Written Notice in Appropriate non-English Language
Brochure
Other (If Other, please explain in the space below)
N/A

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F. Did your agency/organization incur any additional costs during the previous calendar year related to providing
LEP assistance?

D

Yes
No

G. If so, what were your agency/organization's costs for the previous calendar year in providing LEP assistance?
$
H. Section 504 of the Rehabilitation Act of 1973, as amended, provides that no qualified individuals with
disabilities shall, on the basis of disability, be excluded from participation in, be denied the benefits of, or
otherwise be subject to discrimination under any program or activity that receives or benefits from Federal
assistance from GSA. (GSA's implementing regulation for Section 504 is located at 41 CFR 101-8.3, et. seq.)

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This chart refers to public access areas only, do not include work-only areas in your answers.
(i) For each of the following areas listed below, indicate whether your agency/organization's facilities are
accessible to individuals with disabilities: (For more information about the applicable accessibility standards,
please check the instructions).

Area

Do you have the following? Do these items comply with applicable disability standards?
(Yes or No)
(Yes or No)

Telephone

Yes

No

Yes

No

Restrooms

Yes

No

Yes

No

Water Fountains

Yes

No

Yes

No

Hallways

Yes

No

Yes

No

Entrance/Exits

Yes

No

Yes

No

Lounges

Yes

No

Yes

No

Cafeteria

Yes

No

Yes

No

Elevators

Yes

No

Yes

No

Conference Rooms

Yes

No

Yes

No

Work/Study Areas

Yes

No

Yes

No

Classrooms

Yes

No

Yes

No

Parking

Yes

No

Yes

No

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(ii) How does your agency/organization provide assistance to individuals that are hearing-impaired and/or to
individuals who are visually impaired? Please explain.

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GSA XXXX XX/20XX PAGE 4

I. Title IX of the Education Amendments Act of 1972 provides that, except as where exempt under the law, no person
shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to
discrimination under any education or training program conducted by a recipient of Federal financial assistance.
Implementing regulations require that where recipients conduct or provide education or training programs, they
must: (1) Designate a Title IX coordinator; (2) Establish a written policy with regard to Title IX and disseminate such
policy--Title IX coordinator's name and contact information should be included in such policy; and (3) Establish
procedures to promptly and equitably resolve complaints that allege discrimination on the basis of sex in the
agency/organization's education programs or activities.

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(i) Does your agency/organization offer any type of training or educational programs/activities?
Yes
No

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(ii) If so, please describe type(s) of training/educational programs/activities, the target audience of such programs/
activities, and recruitment/admission criteria/process:

(iii) Does your agency/organization have an administrative grievance procedure established should an individual
wish to file a sex-based complaint with regard to the way in which your agency/organization operates its
educational or training programs/activities?
Yes
No

A

III. Marketing/Advertisement of Programs and Activities
A. Does your agency/organization market and/or advertise your programs, activities, benefits, or services?
Yes
No
B. Please describe the way in which your agency/organization ensures that individuals who are eligible to
participate in your federally assisted programs and activities are aware of and have a full and fair opportunity to
participate.

F

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IV. Complaint Information

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Individuals have the right to either (1) file an administrative complaint with GSA based on discrimination in federally assisted
programs or activities (GSA only has jurisdiction over recipients of Federal surplus property); or (2) file a lawsuit in Federal
court. Complainants may also have other avenues available.
With regard to the way in which your agency/organization operates/administers its federally assisted programs and/
or provides services/benefits:
A. Have any complaints (oral or written, informal or formal), lawsuits, charges, inquires, etc. been filed with any
Federal, State, or Local agency, alleging that your agency/organization--or any component thereof--discriminated
against an individual or individuals on the basis of race, color, national origin, sex, disability, or age?
Yes
No

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B. If so, please provide the following for each complaint received or filed for the last two calendar years:
(If additional space is required, add as an attachment page)
Date of Complaint

Basis (i.e., race, national origin, etc.)

Issue(s)

Status of Complaint

A

V. Information Regarding Your Participation in the Federal Surplus Property Program
A. How did your agency/organization learn about the program?
Word of Mouth
Information Briefing/Presentation
Television or Radio
Newspaper
Mailing
Internet
Other (If Other, please explain in the space below)

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B. How does your agency/organization find out about the availability of the property?

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C. Has your agency experienced problems in the past in obtaining the type of property your agency/organization
needs?
Yes
No

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D. How would you rate the quality of the property that your agency/organization has received through the Federal
Surplus Property Program?
Excellent
Good
Fair
Poor
VI. Unavailable Compliance Data
Federal civil rights laws and regulations require recipients of Federal financial assistance to collect and maintain compliance
data and, upon request, provide such data - as requested by the Federal agency - for the purpose of determining compliance
with applicable Federal civil rights laws and regulations.

A

A. Is your agency/organization unable to provide any of the information requested in this submission?
Yes
No
B. If so, please identify the corresponding number and/or type of data that your agency/organization is unable to
provide (as requested above) due to unavailability of such data.

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C. Briefly describe your agency/organization's plan(s) to begin collecting and maintaining such data for future
requests regarding civil rights compliance. Your plan should provide dates and action(s) that will be taken to ensure
such data is collected and maintained. The Office of Civil Rights is available to provide assistance in developing
such a plan.

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VII. Amount of Time to Submit this Questionnaire
A. Please provide the estimated amount of time that your agency spent in completing this compliance submission.
Number of Hours:

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Number of Minutes:

A

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