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    Fitness to Teach Member of the Public Referral Form

    Page 1 of 6

    Your details

    Title

    Surname

    Forename

    Middle Name/Initial

    Address Line 1

    Address Line 2

    Town/City

    Country

    Postcode

    Email address

    Home/Work Telephone Number

    Mobile Number

    Preferred Contact Method


    Fitness to Teach Member of the Public Referral Form

    Page 2 of 6

    Teacher details

    Surname *

    Forename

    Middle Name/Initial

    School/College/Organisation *

    Address Line 1

    Address Line 2

    Town/City

    Country

    Postcode

    Employer of Teacher


    Fitness to Teach Member of the Public Referral Form

    Page 3 of 6

    Misconduct Allegations

    • Please provide a short summary of the allegations that form your complaint stating specific incidents, dates, names and contact details (where possible) of witnesses to the incidents you are referring. Please note that we will be in touch with you if you need to provide additional information.
    • You can enter a maximum of three allegations with two witnesses for each within this section. The witnesses should have witnessed the alleged behaviour and can include the Investigating Officer, Local Authority staff, teachers, employees, members of the public, pupils.
    • For guidance please refer to GTC Scotland's Code of Professionalism and Conduct (COPAC).

    Allegation 1

    Allegation/Incident Category *

    Allegation Description *

    Start Date *

    End Date

    If this allegation/incident does not have any witnesses, please proceed to the submit button/next section

    Witness(es)

    This form only allows for a maximum of three witnesses to be included. Please include the three main witnesses to the alleged behaviour.

    Allegation 1 - Witness 1

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 1 - Witness 2

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 1 - Witness 3

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    --

    Allegation 2

    Allegation/Incident Category

    Allegation Description

    Start Date

    End Date

    If this allegation/incident does not have any witnesses, please proceed to the submit button/next section

    Witness(es)

    This form only allows for a maximum of three witnesses to be included. Please include the three main witnesses to the alleged behaviour.

    Allegation 2 - Witness 1

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 2 - Witness 2

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 2 - Witness 3

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    --

    Allegation 3

    Allegation/Incident Category

    Allegation Description

    Start Date

    End Date

    If this allegation/incident does not have any witnesses, please proceed to the submit button/next section

    Witness(es)

    This form only allows for a maximum of three witnesses to be included. Please include the three main witnesses to the alleged behaviour.

    Allegation 3 - Witness 1

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 3 - Witness 2

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details

    Allegation 3 - Witness 3

    Witness Surname

    Witness Forename

    Witness Telephone Number

    Witness Email Address

    Does the individual know you are raising the above allegation(s) with GTC Scotland?

    Does the individual have any concerns about the allegation(s) you are referring to GTC Scotland?

    If yes, please give details


    Fitness to Teach Member of the Public Referral Form

    Page 4 of 6

    Action Taken

    Have you raised this referral with the teacher who is the subject of your referral? *

    If yes, please detail the outcome

    Have you raised this referral with the headteacher? *

    If yes, please detail the outcome

    Have you raised this referral with the employer of the teacher concerned? *

    If yes, please detail the outcome

    Please indicate any other official body you have raised this referral with

    Please detail the outcome


    Fitness to Teach Member of the Public Referral Form

    Page 5 of 6

    Documentary Evidence

    Please use the following checklist to indicate and attach documentary evidence required by GTC Scotland at this stage to conduct an investigation.

    Letters

    Emails

    Photographs, video, audio or other recordings

    --

    Please provide details of any other teachers involved

    Teacher 1

    Surname

    Forename

    Middle Name/Initials

    School/College

    Address Line 1

    Address Line 2

    Town/City

    Country

    Postcode

    Teacher 2

    Surname

    Forename

    Middle Name/Initials

    School/College

    Address Line 1

    Address Line 2

    Town/City

    Country

    Postcode


    Fitness to Teach Member of the Public Referral Form

    Page 6 of 6

    Declaration

    Please read the following declaration statement and check the box prior to submission.

    I confirm that all of the information provided is true and correct. I permit GTC Scotland to process this referral and to use the information provided to do so.

    I understand and accept that in order to process this referral GTC Scotland may need to disclose the information provided by me to other persons (including the teacher who is the subject of the referral) and make any further necessary enquiries.

    I have read and understood the Threshold Policy.

    I understand that should this referral come to be considered by GTC Scotland's Fitness to Teach Panel, I and others may be required to answer questions at such a Hearing and can be cross-examined under oath.

    I understand that should the teacher concerned be found unfit to teach, or if it is found that their fitness to teach is impaired, that teacher may have their name removed from the Register of Teachers.

    Please be aware that by clicking submit, your form will be sent to GTCS and you will not be able to amend the form. Please ensure that all information is accurate before submitting.


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