ST CLAIR COUNTY, ILLINOIS THIRD PARTY CONTRACTOR TITLE VI QUESTIONNAIRE PRE- CONTRACTING STAGE QUESTIONNAIRE As a recipient/sub-recipient of Federal grant funding St Clair County is required to ensure that all of its sub-contractors on each of its projects are in compliance with Title VI and the rules, regulations, and executive orders that govern Title VI on federally funded projects. In order to ensure that the third party contractors engaged on St Clair County's projects are in compliance, your organization must complete the following questionnaire in its entirety. If you have any questions regarding this questionnaire please contact St Clair County's Title VI Coordinator at the address or phone number provided below. Please submit your completed questionnaire and all additional materials to the Title VI Coordinator. Linda Franks Title VI Coordinator 10 Public Square Belleville, IL 62223 Phone: 618-825-3266 (if no answer 618-277-6790) Fax: 618-236-1190 Email: titlevi@co.st-clair.il.us Date of Report Name of Organization Project Name Please answer the following questions completely. If the question asks you to provide additional information please include it in the space provided or attach additional sheets. If additional sheets are used, then please indicate the question number you are answering by typing or writing the appropriate question number and/or part in the upper left-hand corner. Attach all requested additional materials to this questionnaire. TITLE VI PLAN & COMPLAINT PROCEDURE 1. In the past three (3) years has your organization had a Title VI complaint filed against it? Yes No A. If Yes, in the space provided below, please describe for EACH complaint: the date, the nature of the complaint, who was involved, what action was taken, and the outcome. ST CLAIR COUNTY THIRD PARTY CONTRACTOR TITLE VI QUESTIONNAIRE PRE-CONTRACTING STAGE QUESTIONNAIRE NON-DISCRIMINATION POLICY & STATEMENT = Page 1 = 2. Does your organization have a nondiscrimination policy that is incorporated into a Statement of Nondiscrimination? Yes No A. If Yes, did you provide a copy of this policy/statement to St Clair County? Yes No 3. If your organization does not have its own nondiscrimination policy/Statement of Nondiscrimination, it is required to follow St lirounty’s policy and use its Statement of Nondiscrimination. Do you have a copy of the county's nondiscrimination policy/statement of nondiscrimination? Yes No A. If No, do you know who to contact to obtain a copy or where you can find a copy of St Clair Yes No ounty’snondiscrimination policy/statement of nondiscrimination? CIVIL RIGHTS AND/OR TITLE VI COORDINATOR 4. Does your organization have a person employed for it that is responsible for handling civil Yes No rights issues and/or a Title VI coordinator? A. If Yes, please provide the name, title, and contact information for that employee. Name Title Address Phone Number Fax Number Email Address SUBCONTRACTING, LEASING, PURCHASING 5. Does your organization have a federally compliant, competitive procurement process? Yes No A. If Yes, have you provided the county a copy of your organization's written procurement Yes No procedures? 6. If your organization does not have its own federally compliant, competitive procurement Yes No process, it is required to follow tlirounty’s procurement procedures. Do you have a copy of thounty’s procurement procedures? A. If No, do you know who to contact to obtain a copy or where you can find a copy of Yes No St lirounty’sprocurement procedures? 7. Does your organization plan to enter into subcontracts on this project? Yes No A. If Yes, have you provided St Clair County with a copy of your proposed competitive Yes No procurement documents? B. If Yes, to #7, have you provided the county with a copy of your proposed subcontract(s) Yes No for the project? SIGNATURE OF AUTHORIZED REPRESENTATIVE By signing below, I certify that I am authorized to sign this report and that the information contained in this report is accurate and complete. Signature Date Printed Name Title = Page 2 =