K-1531   ©   KEC-E  

EXHIBIT

PUBLIC  CONCERNS / COMPLAINTS
ABOUT  INSTRUCTIONAL  RESOURCES

CITIZEN'S REQUEST FOR RECONSIDERATION
OF INSTRUCTIONAL MATERIAL

Author   ______________  Hardcover   ____ Paperback   _____ Other media   _______

Title__________________________________________   Copyright date   __________

Publisher (if known)   ____________________________________________________

Request initiated by____________________________   Telephone   ______________

Address   ________________________________________________________________

Complainant's E-mail address   ____________________________________________

Complainant
represents:   
¨   himself or herself

   
¨   (name organization):   _____________________________________

   ¨   (identify other group):   ____________________________________

Please  use  the  reverse  side  for  additional  space  or  comments

To what in the material do you object?  (Please be specific; cite pages.)

What do you feel might be the result of the use of this material?

For what age group would you recommend this material?

What do you feel is good about this material?

Did you review the entire material?______   What parts?

Are you aware of the judgment of this material by literary critics?

What do you believe is the theme of this material?

Are you aware of the instructional purpose in using this work?

What would you like the District to do about this material?

¨   Do not assign or recommend it to my child (children).
¨   Do not assign it to students.
¨   Withdraw it from all patrons of the library.
¨   Refer it to an official committee for reevaluation.

In its place, what material of equal literary quality would you recommend that would convey as valuable a picture and perspective?



_________________________________________________   __________________
Signature of complainant   Date