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DJJ OMBUDSMAN REFERRAL FORM 
Date & Time: 
 
  Type of Activity:
 
 
 




  
  Information Submitted By:
 Last Name:
 First Name:
 Street Address:
 City:
 State:
 Zip:
 Phone: (XXX-XXX-XXXX)
 Email:
  Juvenile Information:
 Last Name:
 First Name:
 DOB: (MM/DD/YYYY) Calendar
 Facility Assigned:
  Complaint / Inquiry:
(Character Limit = 300)  
Have you attempted to resolve this matter with someone else?
If yes, who did you contact:
Date contacted: (MM/DD/YYYY) Calendar
What happened:
(Character Limit = 300)  
 
Contact Us
 
Herman Archie, Ombudsman
Office of Ombudsman, 3408 Covington Highway, Decatur, Georgia 30032
Phone: 1-855-396-2978 / Fax: 404 508-7271 Email: djjombudsman@djj.state.ga.us
 
   
 
   
 

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3408 Covington Highway - Decatur, GA - 30032
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Phone: 404-508-6500 / Fax: 404-508-7289
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