Request for Reconsideration of Instructional/Library Materials Form
To prevent misunderstanding of your complaint, please fill in the following information.
Request initiated by:
NAME_______________________________________________________________________________________
ADDRESS____________________________________________________________________________________
PHONE NUMBER_____________________________________________________________________________
Representing:
STUDENTS NAME_______________________________________________________________________
ORGANIZATIONS NAME________________________________________________________________
OTHER________________________________________________________________________________
Type of Instructional or Library Material:_______________________________________________________
Title:_________________________________________________________________________________________
Author/Publisher/Producer:___________________________________________________________________
Library___________________ Class Name_____________________ Other____________________________
What would you like your school to do about this matter?
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Have you either read, heard or seen the material or media in its entirety? If not, what part did you see, read or hear? Please specify page numbers or time if only read, heard, or seen specific parts. ____________________________________________________________________________________________
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To what in the instructional or library material or media do you object? (Please be specific. For example, cite page or section.) ____________________________________________________________________________________________
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What do you feel may result from the use of this material or media?
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What do you believe is the theme of this material or media?
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For what age group would you recommend this material or media?
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What do you find good about this material or media?
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Are you aware of the judgments of this work by literary or other critics?
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In view of the action you would like to take, do you have any suggestions about material or media that could be substituted that would convey as valuable a picture and perspective of the subject treated and would meet the educational needs of your child and/or other students?
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____________________________________________________________________________________________
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Signed__________________________________________ Date___________________________
Thank you for your time and concern. Please return this completed form to the District Administrator who will review its contents and will notify you of the next step in the complaint process.
