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