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 
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