Request For Reconsideration Of Instructional/library Materials Form
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1CURRICULUM AND INSTRUCTION
08.2322 AP.21
Request for Reconsideration of Instructional/Library Materials
S
________________________________ T
____________________________
CHOOL
EACHER
Please indicate the format of the material (book, DVD, magazine, CD, etc.):
_____________________________________________________________________________________________
T
_______________________________________________________________________________
ITLE
A
____________________________________________________________________________
UTHOR
P
/P
________________________________________________________________
UBLISHER
RODUCER
Request initiated by ___________________________________________________________________
Telephone ________________________ Street Address _____________________________________
City ___________________________________ State ______________ ZIP Code _________________
himself herself organization, specify _______________________
Complainant represents
Please answer the following questions after you have read, viewed, or listened to the school
instructional/library material in its entirety.
YES
NO
1.
Have you read, viewed, or listened to the material in its entirety?
YES
NO
2.
Have you discussed this work with the teacher/librarian who assigned/ordered it?
3.
What do you find objectionable in the material? (Please be specific, cite page(s), scenes, etc.)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4.
What do you believe is the theme or purpose of this material? ______________________________________
_________________________________________________________________________________________
What do you feel might be the result of a student’s using this material? _______________________________
5.
_________________________________________________________________________________________
6.
For what age group would you recommend this material? __________________________________________
_________________________________________________________________________________________
7.
Is there anything good in this material? Please comment. __________________________________________
_________________________________________________________________________________________
8.
Would you care to recommend other school library material of the same subject and format as a replacement?
_________________________________________________________________________________________
9.
What action do you desire school personnel to take as a result of this written request for reconsideration?
_________________________________________________________________________________________
If sufficient space is not provided, attach additional sheets. Please sign your name to each additional attachment.
_______________________________________________
_________________________
Complainant’s Signature
Date
P
P
.
LEASE RETURN COMPLETED FORM TO THE SCHOOL
RINCIPAL
Review/Revised:6/28/10
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