Georgia Professional Standards Commission
Complaint Form
Date of Complaint* ____________________________________________________________________________________
Educator’s Full Name* _________________________________________________________________________________
Educator’s Address ____________________________________________________________________________________
Educator’s Work Phone ________________________________________________________________________________
Educator’s School System or Agency* _____________________________________________________________________
Educator’s School or Program* ___________________________________________________________________________
Educator’s Employment Position* _________________________________________________________________________
Standard(s) of the Code of Ethics for Educators that has been breached
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Brief, specific description of how the educator has allegedly breached the Code of Ethics for Educators (include dates and time
of alleged violations)* _________________________________________________________________________________
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*Information Required - An unsigned complaint cannot be processed.
Complainant’s Email Address* ___________________________________________________________________________
Complainant’s Phone Number* _______________________________Fax Number _________________________________
Complainant’s
Address* ________________________________________________________________________________
Complainant’s
Signature* _____________________________________________________________________________
Name of Person(s) Filling the Complaint*___________________________________________________________________
addresses and telephone numbers if known. Attach pertinent documentation or evidence.
Attach a list of witnesses and other persons who have knowledge of the facts alleged in the complaint. Include names,
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Contact Numbers: (404) 232-2700 or (800) 537-5996 FAX (404) 232-2720.
Mail to: Educator Ethics,
200 Piedmont Avenue, Suite
1712, Atlanta, GA 30334-9032
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