USVI Public Records

Document text

Government of the Virgin Islands of The United States Department of Public Works Division of Transportation GENERAL COMPLAINT / ADA COMPLAINT FORM ___________________________________________________________________________ Section 1: Passenger Information: Name of Complainant: ______________________________________________ Mailing Address: ___________________________________________________ E-Mail Address: ________________________________ Phone Number (with area code):___________________ Preferred Contact Method (select one): ___ Phone ___ E-Mail ___ US Mail____ Accessible Format Requirements: ___ Large Print ___ TDD ___ Audio______ Other: _________________ Section II: Is this an ADA complaint for discrimination based on a disability? ____ Yes ____ No Are you filing this complaint on your own behalf? ___ Yes ___ No If not, please provide the name of and your relationship to the person for whom you are filing this complaint: Name: _________________________________ Relationship: ______________________________ Section III: Incident Information Date of alleged Incident occurred: _________________Time of day: ______________ Explain as clearly as possible what happened. Describe all persons involved. Include names and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses. If more space is needed, please attach additional sheets. __________________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Section IV: Administration Have you filed a complaint with any other Federal, State, or local agency? ___ Yes ___ No If yes, please specify the name of the agency or court where you have filed this complaint. Name of agency or court: __________________ Please provide information about a contact person at the agency/court where the complaint was filed. Name: __________________Title: _____________________________ Agency:________________ Address:____________________________________Tel.# ______________ Note: You may attach any written materials or additional information you feel is relevant to your complaint._________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________ Please mail this completed ADA Complaint Form to the ADA Coordinator at the following address: Department of Public Works, Heather Stephenson-Proctor, Territorial ADA Coordinator, Division of Transportation, 6002 Estate Anna’s Hope, Christiansted, St. Croix, VI 00820-4428