1312/6161.12 Form

(Name of District)

Request for Reconsideration of Instructional Materials

Title ________________________________________________________________________

Author __________________________________________ Publisher _____________________

Request initiated by ________________________________

The concerning material was located in or obtained from:

[ ] Library [ ] Classroom

If classroom: Grade level ____

Course Name ______________________

Teacher/Staff ______________________

The questionable material was:

[ ] Required of all students in a class.

[ ] Required supplemental reading.

[ ] Recommended reading from an assigned list.

[ ] Recommended by the librarian or staff member.

[ ] Independently selected by the student.

[ ] Other. Please specify ________________________________________________________________
____________________________________________________________________________________

The material is best described as a:

[ ] Book

[ ] Video or Online Content

[ ] Periodical/Magazine

[ ] Technology Related Program

[ ] Other Media. Please specify ____________________________________________________

Please answer the following questions:

1. Did you read, view, or listen to the entire work? If not, what parts did you examine?

_______________________________________________________________________________

2. In what specific ways do you think this work is inappropriate for students?

_______________________________________________________________________________

3. What have you been told about the instructional purpose of this material?

_______________________________________________________________________________

4. What do you believe is the theme or purpose of this material?

_______________________________________________________________________________

5. What age group would you recommend this material?

_______________________________________________________________________________

6. Are you aware of the judgment of this work by literary critics and/or professional educators/organizations?

_______________________________________________________________________________

7. What are the valuable aspects of this material?

_______________________________________________________________________________

8. What do you feel may be the results of students reading, listening to, or viewing this material?

_______________________________________________________________________________

9. What work/material of equal or superior value would you recommend to replace the one in question?

_______________________________________________________________________________

10. What would you like the school to do regarding this book/material?

[ ] Do not assign it to my child.

[ ] Withdraw it from circulation.

[ ] Re-evaluate its use or availability in the school.

____________________________________________ ________________________
Signature of Complainant Date