DJJ OMBUDSMAN COMPLAINT FORM  Date & Time:

Type of Activity:  Health Concerns  Contraband  Facility Safety/Security Community Safety/Security Religious Services Education Sexual Abuse(PREA) Youth Safety Other:

Information Submitted By:  Last Name:  First Name:  Street Address:  City:  State: ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  Zip:  Phone: (XXX-XXX-XXXX)  Email:

Juvenile Information:  Last Name:  First Name:  DOB: (MM/DD/YYYY)  Facility Assigned: -- Please Select -- YDC RYDC Community

Complaint / Inquiry: (Character Limit = 300)   Have you attempted to resolve this matter with someone else? YesNo If yes, who did you contact: -- Please Select-- Facility Director Assistant/Associate Director JDC Counselor Grievance Officer Regional Administrator District Director JPPS JPMS Other Date contacted: (MM/DD/YYYY) What happened: (Character Limit = 300)

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Office of Ombudsman, 3408 Covington Highway, Decatur, Georgia 30032

Phone: 1-855-396-2978 / Fax: 404 508-7271 Email: djjombudsman@djj.state.ga.us