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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