Complaints Concerning Instructional Materials

REQUEST FOR RECONSIDERATION OF EXISTING INSTRUCTIONAL MATERIALS This form is only for use by district employees, district residents, or parents/guardians of students enrolled in a district school to challenge the content or use of any existing textbook, instructional material, supplemental instructional material, or other curriculum for classroom instruction, or any book or other resource in a school library. Date:____________________________________________________________________________________________________________ Name of person filing complaint (Required): __________________________________________________________________ Group represented (if any):_____________________________________________________________________________________ Phone:___________________________________________________________________________________________________________ E-mail address:__________________________________________________________________________________________________ Address:_________________________________________________________________________________________________________ Instructional Material Being Challenged: Title:_____________________________________________________________________________________________________________ Author:__________________________________________________________________________________________________________ Publisher:_______________________________________________________________________________________________________ Date of Edition:_________________________________________________________________________________________________ Name of school/classroom instructional material was used:__________________________________________________ - Please specifically state the nature of your concern or objection and identify your objection by page, website, webpage and/or link, recording or digital sequence, video frame, or words, as appropriate. You may use additional pages if necessary. __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ - Was the instructional material of concern read/heard/viewed in isolation or was the entire selection read/heard/viewed? If the entire selection was not read/heard/viewed, what is your estimate regarding the percentage of the amount read/heard/viewed? __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ - What is your concern regarding the consequence if a student reads/hears/views the instructional material? In your assessment, is the instructional material appropriate for the age of the students being taught? __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ - What would you like the school to do about the instructional material? __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ___________________________________________________________________ Signature of complainant For District Use: Request received by:___________________________________________________________________ Date:___________________________________________________________________ Title:___________________________________________________________________ Action taken:___________________________________________________________________ Date:___________________________________________________________________