application 2020 transportation growth management grant · 2020. 8. 4. · application instructions...

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2020 Transportation Growth Management Grant Application Instructions Be sure to download and review the 2020 application packet before filling out this grant application. The application packet, additional resources, and examples of successful applications can be found on the TGM planning grants page. You can save your progress and revisit this form at any time by clicking the "Save" button at the bottom of each page. Applications must be received by July 31, 2020 at 11:59 p.m. (PDT) Applicant information Instructions: Complete this information for the applicant. Provide both a designated contact and an authorized representative (if different than the designated contact) for your entity. The authorized representative is someone who is authorized to make decisions and sign a funding agreement with ODOT should your project be chosen for funding. Primary applicant jurisdiction City of West Linn Mailing address 22500 Salamo Road, West Linn, Oregon 97068 Website https://westlinnoregon.gov/ Contact person name Jennifer Arnold Contact person title Associate Planner Contact phone (503) 742-6057 Contact email [email protected] Would you like to receive TGM news and updates? I am already subscribed Authorized representative name, if different from the applicant contact

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Page 1: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

2020 Transportation Growth Management Grant ApplicationInstructionsBe sure to download and review the 2020 application packet before filling out this grant application.

The application packet, additional resources, and examples of successful applications can be found on the TGM planning grants page.

You can save your progress and revisit this form at any time by clicking the "Save" button at the bottom of each page.

Applications must be received by July 31, 2020 at 11:59 p.m. (PDT)

Applicant informationInstructions: Complete this information for the applicant. Provide both a designated contact and an authorized representative (if different than the designated contact) for your entity. The authorized representative is someone who is authorized to make decisions and sign a funding agreement with ODOT should your project be chosen for funding.

Primary applicant jurisdictionCity of West Linn

Mailing address22500 Salamo Road, West Linn, Oregon 97068

Websitehttps://westlinnoregon.gov/

Contact person nameJennifer Arnold

Contact person titleAssociate Planner

Contact phone(503) 742-6057

Contact [email protected]

Would you like to receive TGM news and updates?I am already subscribed

Authorized representative name, if different from the applicant contact

Page 2: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

Darren Wyss

Authorized representative titleActing Planning Manager

Phone(503) 742-6064

[email protected]

List other participating local jurisdictions (if any)List other participating local jurisdictions (if any)Participating local jurisdiction Providing match?

Project name and locationProject titleHighway 43 Corridor: Land Use and Bicycle and Pedestrian Connectivity Analysis

Project area: Using either of the two fields below, attach a map of the project area or describe the area your project is located in.

Option 1: Project area map Option 2: Project area descriptionNorthern West Linn City Limits on Highway 43 (Willamette Drive) to the Highway 43 (Willamette Drive)/ Hidden Springs Road Intersection.

ODOT region (1-5)Region 1

ODOT Region Map

Type of grantCategory 2: Integrated Land Use & Transportation Planning

Summary description of projectAn evaluation of Highway 43 zoning and uses for a mixed use designation or overlay zone recommendation. Also included with this analysis is a review of the existing and potential pedestrian and bicycle connectivity between the residential neighborhoods and Highway 43 amenities.

Project cost table

Page 3: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

TGM funds requested

Consultant$140,500.00

Local reimbursement$23,000.00

Total TGM funds requested$163,500.00

Local match 12% minimum (calculated)$22,295.45

Match to be provided

Labor, supplies and services during project$23,000.00

Payment when Intergovernmental Agreement is signed

CertificationsCertificationsThis application was prepared by staff of the primary applicant or staff of one of the involved jurisdictions

Certifications checkboxBy checking this box, I certify that my organization listed above supports the proposed project, has the legal authority to pledge matching funds, and has the legal authority to apply for Transportation and Growth Management funds. I further certify that matching funds are available or will be available for the proposed project.

Eligibility requirements

Applications are reviewed on a pass/fail basis on each of the following three requirements.

Applications found to not meet each of these requirements will not be scored against the award criteria and will not be awarded a grant.

1. Clear transportation relationship

A proposed project must have a clear transportation relationship and produce transportation benefits. A project must entail analysis, evaluation and selection of alternatives, development of implementation actions, and public involvement that results in a long range transportation plan, land use plan, or other product that addresses a transportation problem, need, opportunity, or issue of local or regional importance.

Certification: Clear transportation relationshipBy checking this box, I certify that the project meets this eligibility criterion.

Page 4: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

2. Adoption of products to meet project objectives

A proposed project must include preparation of an adoption-ready product or products that lead to a local policy decision and that directly address the project objectives, such as a transportation system plan, comprehensive plan amendment, land use plan, code amendment, implementation program, or intergovernmental agreement. Projects are expected to include adoption hearings (or equivalent) by the governing body or to prepare products which will be adopted as part of a larger project.

Certification: Adoption of products to meet project objectivesBy checking this box, I certify that the project meets this eligibility criterion.

3. Support of local officials

A proposed project must clearly demonstrate that local officials, both the primary applicant and any co-applicants, understand the purpose of the grant application and support the project objectives. A resolution of support, meeting minutes, or authorized letter from the governing body of all applicants (e.g. City Council, Board of Commissioners, or Transit Board) must be submitted with the application to meet this requirement.

Upload your resolution, minutes or authorized letter from governing body of applying jurisdiction(s) here:TGM CC Letter of Support.pdf

Award criteria

Criterion 1: Proposed project addresses a need and supports TGM objectives (up to 40 points)

The project clearly and effectively addresses a local or regional transportation or transportation-related land use issue, problem, need, or opportunity and will achieve one or more of the TGM objectives.

Application instructions and example responses can be found here.

Explain how your proposed project addresses a need and supports TGM objectivesCurrent zoning along HWY 43 is a blend of commercial and residential, with many of the properties currently underutilized. With the corridor being an important regional transportation route and the primary transit route for the community, the City is interesting in exploring mixed-use zoning to re-energize the corridor. This project can leverage prior state and regional investments in road improvements to move the vision forward. The primary goals of the project are: Evaluate land uses adjacent to the corridor and recommend zoning changes, amended code language, and potentially design standards; and evaluate pedestrian/bicycle connections to safely access the corridor from surrounding neighborhoods and recommend prioritized infrastructure improvements and financing options. The outcome of this effort will create a destination corridor that is an inviting opportunity for residents to live, work, and move about safely with ease. The City is committed to providing safe multi-modal transportation options/alternatives in the corridor through implementation of the adopted 2016 Highway 43 Concept Plan. The plan calls for continuous

Page 5: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

sidewalks and grade-separated cycle tracks along both sides of the corridor. With the hope of creating a destination corridor that has high-quality pedestrian/bicycle amenities, getting to the corridor safely is vitally important for the Robinwood neighborhood. This is an older part of the community that lacks sidewalks and getting safely to services or transit is a challenge.This project will identify pedestrian/bicycle improvements to provide safe access to the HWY 43 corridor, where significant state, regional, and local funds will be spent, from the surrounding neighborhoods. This plan will create safe links between planned improvements along HWY 43 and adjacent neighborhoods and allow citizens to access new opportunities within the corridor without needing to drive. The City hopes to increase transportation balance and mobility choices in the community. Place making is an important principle in the City of West Linn and work to transform the HWY 43 corridor into a series of lively neighborhood centers has been ongoing for years. The proposed project for the north end of the corridor will result in similar outcomes with the goal of reinvigorating the area with a mix of housing types, work places, shops, and parks for people of all ages, incomes, and abilities. Through appropriate zoning changes, a neighborhood center will be created and safe pedestrian/bicycle access routes to the center will be identified. Providing the pedestrian/bicycle connections from the adjacent neighborhoods will be important to encourage travel by means other than an automobile, foster community, and also leverage the state, regional, and local investments being made along the corridor to improve the multi-modal environment to make it more appealing for modes other than the automobile. The project is timely as improved zoning along the corridor to allow a better mix of housing and commercial can help the City achieve the goals of HB 2001/2003. Existing conditions along the HWY 43 Corridor have been continuously documented beginning in 2008 with the original Highway 43 Concept Plan, to the 2016 West Linn Transportation System Plan and the updated 2016 Highway 43 Concept Plan. These documents provide a solid baseline for traffic projections, level of service deficiencies, and environmental conditions to be used in the analysis of the HWY 43 Corridor.Currently, the disjointed land uses and zoning along the corridor consists of large residential lots with single-family homes, single-story commercial strip developments, and some multi-family condo developments. The ultimate purpose of this project would be to identify areas where zoning designations could be amended to allow for more efficient use of underutilized properties and creating the envisioned neighborhood center that will accommodate existing and future residents, businesses, and services. In addition, the project will identify bicycle and pedestrian access improvements to encourage adjacent neighborhoods to visit the revitalized corridor and shop locally. The corridor is used by citizens of other communities such as Lake Oswego and Oregon City. We want to create a destination corridor that is walkable/bicycle friendly for all who use the services, so it is important that those services are compact. With the hope of creating a destination corridor that has high-quality pedestrian/bicycle amenities, getting to the corridor safely is of vital importance for the Robinwood neighborhood, and all users of the corridor. Users passing through from nearby communities could have the luxury of parking in one place and walking to all services safely throughout the corridor. Citizens near the corridor can take advantage of walking/biking with the family from home to enjoy the amenities within the corridor.

Criterion 2: Proposed project is timely and urgent (up to 25 points)

The application demonstrates timeliness and urgency. The project is needed now to:

address pressing local transportation and land use issues

make amendments to local plans or regulations necessitated by changes in federal regulations, state requirements or regional plans

make amendments to local plans or regulations necessitated by changes that were not anticipated in previous plans, including growth or lack of growth, changes in land-use patterns or changes in

Page 6: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

available funding

build on, complement or take a necessary step toward completing or implementing other high priority community initiatives, including Governor's Regional Solutions Team priority

resolve transportation or land use-related issues affecting the project readiness of local, regional or state transportation projects for which funding is expected to be obligated within the near future

Application instructions and example responses can be found here.

Explain how your proposed project is timely and urgentOverview:The City of West Linn has been working to improve Highway 43 for a number of years as it is an important regional transportation corridor and the primary public transit route through the community. The 2008 Robinwood Neighborhood Plan, the 2008 Highway 43 Concept Plan, the 2011 Corridor Visioning process, and the 2016 West Linn Transportation System Plan/updated 2016 Highway 43 Concept Plan have all contributed to the City arriving at this project. The 2016 Highway 43 Concept Plan identified safety and efficiency improvements for all modes of travel along the corridor. It is important to complete this work during this grant cycle, because State and regional funds have been dedicated to begin implementing some of the improvements and the City wants to create a document that will guide the development pattern that maximizes these safety and efficiency improvements for potential economic development opportunities. This analysis and recommendation document will be used to amend the Transportation System Plan, Community Development Code, and Comprehensive Plan to improve economic development opportunities and improve the livability in the Robinwood neighborhood. The goals of the project are to evaluate land uses adjacent to the corridor and recommend zoning changes, amended code language, and potentially design standards, and to evaluate pedestrian and bicycle connections to safely access the corridor from surrounding neighborhoods and recommend prioritized infrastructure improvements and financing options.The study area is focused on the Robinwood neighborhood, from the northern city limits to the Hidden Springs/Highway 43 intersection. This is the same area approved for the first phase of the Highway 43 Concept Plan, and why this project is timely with this TGM grant cycle. As construction on Highway 43 begins, the project would provide the foundation for the land use changes to leverage the infrastructure investments in the corridor. The project is also timely as West Linn was recently awarded grant funding to address middle housing needs stemming from HB2001 and HB2003. This project can be aligned with the findings of the Housing Needs Analysis, Buildable Lands Inventory, and measures for accommodating needed housing by providing an opportunity to expand housing choices in the community.

Criterion 3: Proposed project approach is reasonable (up to 20 points)

The application demonstrates a clear approach to achieving the expected outcome and includes consideration for adoption. Where substantial coordination with other local, regional, and state planning efforts will need to occur, the mechanisms and responsibilities for the coordination are clear.

Application instructions and example responses can be found here.

Explain how your proposed project approach is reasonableIf awarded the grant funds, a consultant would be hired to complete the full analysis of the zoning and transportation aspects of this project. The West Linn City Council has appointed the City’s Economic Development Committee to oversee the project along with the Staff Liaison. A project timeline for deliverables and key stakeholders is below.The outcome of this project is intended to be the foundation of future growth potential in the Highway 43 Corridor. The final product of this project will be a full analysis recommending zone changes for mixed use

Page 7: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

development or an overlay zone which permits such activities. In addition to the zoning analysis, a review of the existing and future bicycle and pedestrian connections along the corridor will be complete. This transportation component is intended to aid in future amendments to the Transportation System Plan allowing for safer and best access from adjacent neighborhoods to the corridor so residents can live, work, and move about safely and with ease.Key Stakeholders:

• Economic Development Committee (appointed by Council as the working group)• Planning Commission• City Council• Property/business owners in effected area • All Neighborhood Associations• ODOT• Department of Land Conservation and Development• Metro• Clackamas County• City of Lake Oswego

Timeline1. Task 1: Project organization: 9/2020 – 12/2020 a. The West Linn Economic Development Committee (EDC) has been appointed as the working group for this project.i. EDC will assist with Consultant selection, scoping, and project scheduleii. EDC will also plan the kickoff meeting b. EDC meeting #1: Project kick-off meeting with selected consultantc. The City will provide the consultant with relevant plans and documents including but not limited to the Comprehensive Plan, Community Development Code, Highway 43 Concept Plan, Transportation System Plan and the most recent Robinwood Neighborhood Plan. d. Appoint a Technical Advisory Committee (TAC) with appropriate jurisdictional staffi. TAC Meeting #1: Staff and consultant will meet with the TAC as an introduction and to discuss the project scope and schedule.2. Task 2: Policy and Planning Requirements: 1/2021 - 5/2021a. EDC Meeting #2: Develop Project Goals and Objectives with the EDC (consultant, EDC, project manager)b. Robinwood Neighborhood Association meeting (Project Manager (Associate Planner Arnold) and the consultant) to meet with the Robinwood Neighborhood Association. c. Outreach to all Neighborhood Associations (project manager and consultant).d. Meet with ODOT (project manager and consultant)e. EDC & TAC Meeting #3:Present the findings of the outreach to the Economic Development Committee and TAC (project manager and consultant)i. Draft/review Tech Memo #1 (Consultant, TAC)3. Task 3: Existing Conditions and Future Needs: 6/2021 – 9/2021a. Identify Zoning and Neighborhood Access Options (Consultant)i. TAC Meeting #2: draft/review tech memo #2 of existing conditions with consultant and project managerb. Draft #1: zoning and pedestrian/bicycle connectivity document using feedback from the outreach process and information gained in the first phase of this process (Consultant)c. EDC meeting #4: consultant and project manager to present the draft document #1. d. A project status update will be presented to the West Linn City Council by the consultant and project manager.e. Draft document will be presented to the Robinwood Neighborhood Association and sent to all other Neighborhood Associations (Consultant, Project manager)4. Task 4: Receive feedback from NA on draft/editing: 10/2021 – 11/2021

Page 8: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

a. Draft #2: Zoning and pedestrian/bicycle connectivity document including neighborhood feedback will be presented to the EDC and TAC in Meeting #5 for feedback and review.b. TAC Meeting #3: Draft tech memo #3 (TAC, consultant)5. Task 5: Joint EDC/CC Meeting: 11/2021 – 2/2022a. The Economic Development Committee and City Council will meet in a work session to discuss second draft along with citizen input. (EDC, consultant, project manager)b. Draft #3: A final draft of the document will be developed following the joint meeting(s) (Consultant)6. Task 6: Legislative Adoption Process: 3/2022 – 6/2022a. The legislative adoption process begins with a work session with the Planning Commission and the Economic Development Committeeb. Following a Planning Commission work session(s) a public hearing will be scheduled for the Planning Commiss

Criterion 4: Proposed project has community support (up to 5 points)

The application demonstrates that there is local support for project objectives, a commitment to participate, and a desire to implement the expected outcome.

Application instructions and example responses can be found here.

Upload letters of support from stakeholders hereTGM PC Letter.pdf

TGM EDC Letter of Support .pdf

TGM_RNA_SignedLetter.pdf

Criterion 5: Proposed project sponsor readiness and capacity (up to 10 points)

The application demonstrates that the local government is ready and able to begin the project within the TGM timetable and that there is local commitment and capability to manage and complete the project. The application demonstrates, if applicable, successful performance on previous TGM projects.

Application instructions and example responses can be found here.

Explain how proposed project sponsor is ready and capableOverview:The City of West Linn has the capacity to manage the TGM funded project and is committed to completion of the project to implement the community’s vision. The West Linn City Council adopted the project as a Council Goal and has appointed the City’s Economic Development Committee as the working group for this project to assist in public outreach and document review. The project manager will be Associate Planner Jennifer Arnold with the support of Interim City Manager John Williams, Acting Planning Manager Darren Wyss, and Associate Planner Chris Myers. As a collective, the team has experience managing a variety of large grant projects including TGM, Metro Construction Excise Tax grants, Periodic Review grants, and DLCD Technical Assistance grants. Specifically, Ms. Arnold has managed a number of grant funded projects during her career as a planner, including implementation of a walking tour map for the City’s historic district and a number of rehabilitation projects in the historic district. In addition, Ms. Arnold managed grant projects while employed with the Oregon Parks and Recreation Department. West Linn has been awarded one TGM grant in the past 10 years. The City successfully completed a TGM grant funded update to its transportation system plan by adopting and implementing the 2016 West Linn Transportation System Plan in March 2016.

Page 9: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

TGM grant funds would be used to fund a consultant to conduct the analysis, assist with community outreach, and develop the final draft of recommendations for adoption. The 12 percent required match will be in the form of staff time spent on the project. West Linn has set aside 0.25 FTE for the project manager devoted to this project.

Required formsTitle VI: Racial & Ethnic Impact Statement formRacial-Ethnic-Impact-Statement.pdf

Download the Racial & Ethnic Impact Statement form here

Today's date7/30/2020

If you encounter any issues with the submittal process, please contact:

Abigail EricksonPlanning Section Web [email protected]

Page 10: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

CITY HALL 22500 Salamo Rd, West Linn, OR 97068 Telephone: (503) 657-0331 Fax: (503) 650-9041

C I T Y O F T R E E S , H I L L S A N D R I V E R S ● W E S T L I N N O R E G O N . G O V

July 13, 2020 Transportation and Growth Management Program Grant Oregon Department of Transportation 123 NW Flanders Portland, OR 97209 RE: West Linn Transportation and Growth Management Program Grant Request Greetings, The West Linn City Council is pleased to support the City’s application for Transportation and Growth Management Program grant funds and appreciates the opportunity to receive assistance in planning for the community’s future. Any awarded funds would be utilized to help the City analyze zoning along the Highway 43 Corridor and improve bicycle and pedestrian connections into the surrounding neighborhoods.

The City of West Linn has been working to improve Highway 43 for a number of years as it is an important regional transportation corridor and the primary public transit route through West Linn. This includes adopting the 2016 Highway 43 Concept Plan that identified safety and efficiency improvements for all modes of travel along the corridor. State and regional funds have been dedicated to begin implementing some of the improvements and the City wants to leverage these investments. The goal of this effort would be to create a destination corridor that is an inviting opportunity for West Linn residents to live, work, and move about safely and with ease.

Sincerely, Russell B. Axelrod, Mayor City of West Linn

Page 11: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project
Page 12: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

CITY HALL 22500 Salamo Rd, West Linn, OR 97068 Telephone: (503) 657-0331 Fax: (503) 650-9041

C I T Y O F T R E E S , H I L L S A N D R I V E R S ● W E S T L I N N O R E G O N . G O V

July 9, 2020 Transportation and Growth Management Program Grant Oregon Department of Transportation 123 NW Flanders Portland, OR 97209 RE: West Linn Transportation and Growth Management Program Grant Request Greetings, The West Linn Economic Development Committee is pleased to support the City’s application for Transportation and Growth Management Program grant funds and appreciates the opportunity to receive assistance in planning for the community’s future. Any awarded funds would be utilized to help the City analyze zoning along the Highway 43 Corridor and improve bicycle and pedestrian connections into the surrounding neighborhoods.

The City of West Linn has been working to improve Highway 43 for a number of years as it is an important regional transportation corridor and the primary public transit route through West Linn. This includes adopting the 2016 Highway 43 Concept Plan that identified safety and efficiency improvements for all modes of travel along the corridor. State and regional funds have been dedicated to begin implementing some of the improvements and the City wants to leverage these investments. The goal of this effort would be to create a destination corridor that is an inviting opportunity for West Linn residents to live, work, and move about safely and with ease. The West Linn Economic Development Committee is also the City Council appointed working group to oversee the project, along with City Staff, as we have a vested interest in the economic growth potential of the City.

Sincerely,

Shannen Knight, Chair West Linn Economic Development Committee

Page 13: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

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Transportation and Growth Management Program Grant

Oregon Department of Transportation123 NW Flanders

Portland, OR 97209

RE: West Linn Transportation and Growth Management Program Grant Request

Greetings,

The West Linn Robinwood Neighborhood Association is pleased to support the City's

application for Transportation and Growth Management Program grant funds and appreciates

the opportunity to receive assistance in planning for the community's future. As a stakeholder

in this project, we take planning for our community's future seriously. Any awarded funds

would be utilized to help the City analyze zoning along the Highway 43 Corridor and improve

bicycle and pedestrian connections into the surrounding neighborhoods.

The City of West Linn has been workingto improve Highway 43for a number of years as it is an

important regional transportation corridor and the primary public transit route through West

Linn. This includes adopting the 2016 Highway 43 Concept Plan that identified safety and

efficiency improvements for all modes of travel along the corridor. State and regional funds

have been dedicated to begin implementingsome of the improvements and the Citywantstoleverage these investments. The goal of this effort would be to create a destination corridor

that is an inviting opportunity for West Linn residents to live, work, and move about safely and

with ease.

Sincerely,

'Z'** /Q'--Dennis A. Pollmann, PresidentWest Linn Robinwood Neighborhood Association

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Page 14: Application 2020 Transportation Growth Management Grant · 2020. 8. 4. · Application instructions andatexample responses can be found here. Explain2016how your proposed project

RACIAL AND ETHNIC IMPACT STATEMENT This form is used for informational purposes only and must be included with the grant application.

Chapter 600 of the 2013 Oregon Laws require applicants to include with each grant application a racial and ethnic impact statement. The statement provides information as to the disproportionate or unique impact the proposed policies or programs may have on minority persons1 in the State of Oregon if the grant is awarded to a corporation or other legal entity other than natural persons.

1. The proposed grant project policies or programs could have a disproportionate or unique positive impact onthe following minority persons:

Indicate all that apply:

Women Asians or Pacific Islanders Persons with Disabilities American Indians African-Americans Alaskan Natives Hispanics

2. The proposed grant project policies or programs could have a disproportionate or unique negative impact onthe following minority persons:

Indicate all that apply:

Women Asians or Pacific Islanders Persons with Disabilities American Indians African-Americans Alaskan Natives Hispanics

3. The proposed grant project policies or programs will have no disproportionate or unique impact on minoritypersons.

If you checked numbers 1 or 2 above, please provide below the rationale for the existence of policies or programs having a disproportionate or unique impact on minority persons in this state. Further provide evidence of consultation with representative(s) of the affected minority persons.

By checking this box, I hereby certify the information contained on this Dated: form is true, complete, and accurate to the best of my knowledge.

Printed Name: Title:

Agency Name:

1 “Minority person” are defined in SB 463 (2013 Regular Session) as women, persons with disabilities (as defined in ORS 174.107), African Americans, Hispanics, Asians, or Pacific Islanders, American Indians and Alaskan Natives.