THE VIRGIN ISLANDS DEPARTMENT OF PUBLIC WORKS
THE VIRGIN ISLANDS DEPARTMENT OF PUBLIC WORKS TITLE VI COMPLAINT FORM SECTION I Name of Complainant: Sex: Race /Ethnic Group: Mailing Address: City: Zip: Home Telephone: Cell Phone: Work Telephone: Email Address: Accessible Format Preferred: SECTION II Are you filling this complaint on your own behalf? ⃞ Yes ⃞No [ If you answered “yes” to this question, go to Section IV.] If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on: ⃞ Yes ⃞ No SECTION III What was the reason you believe you were discriminated against? ⃞Race ⃞Color ⃞National Origin Date of Alleged Discrimination: (Month, Day, Year) What is the name and address of the institution, agency or person that you believe discriminated against you?: Name: Mailing Address: City: Zip: Phone #: Describe how you were discriminated against. What happened and who was responsible? Please be as specific as possible. …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://dpw.vi.gov/wp-content/uploads/2024/01/Title-VI-Complaint-Form-122023.pdf
SHA-256 f635fbf56a2d5ba12d750ae691c2cb8b063b3ecbadd6eebd2b88f501560070d1
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-f635fbf56a2d
Document text
THE VIRGIN ISLANDS DEPARTMENT OF PUBLIC WORKS TITLE VI COMPLAINT FORM SECTION I Name of Complainant: Sex: Race /Ethnic Group: Mailing Address: City: Zip: Home Telephone: Cell Phone: Work Telephone: Email Address: Accessible Format Preferred: SECTION II Are you filling this complaint on your own behalf? ⃞ Yes ⃞No [ If you answered “yes” to this question, go to Section IV.] If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on: ⃞ Yes ⃞ No SECTION III What was the reason you believe you were discriminated against? ⃞Race ⃞Color ⃞National Origin Date of Alleged Discrimination: (Month, Day, Year) What is the name and address of the institution, agency or person that you believe discriminated against you?: Name: Mailing Address: City: Zip: Phone #: Describe how you were discriminated against. What happened and who was responsible? Please be as specific as possible. Attach additional page (s) if necessary Please List Name of persons, witnesses, fellow employees, supervisors, or others whom we may contact for additional information, support or clarification of your complaint: 1. Name: Phone No: 2. Name: Phone No: 3. Name: Phone No: What type of corrective action would you like to see taken? SECTION IV Did you file this complaint with another Federal or local agency; or with a Federal or local court? ⃞Yes ⃞No If answer is yes, check each agency complaint was filed: ⃞ Federal Agency ⃞ Federal Court ⃞ Local Court ⃞ Local Agency Date filed__________________________________________________________ Please provide contact person information for the agency or court where the complaint was filed: Name: Telephone: Address: City: Zip: Please sign and date this complaint form below. Attach any supporting document(s) you think is relevant to your complaint. Signature: _______________________________________________ Date:________________________________ This form can be submitted in person, mail, or email to: Sharon Challenger Program Manager Office of Civil Rights 6002 Estate Anna’s Hope Christiansted, St. Croix VI 00820-4428 Phone: 340.773.1290 x 2242 Fax : 340.773.0670 Email: sharon.challenger@dpw.vi.gov ⃞Large Print ⃞Audio Tape ⃞TDD ⃞Other Disability SIGN