CITIZEN'S REQUEST FOR RECONSIDERATION

OF A BOOK OR OTHER MATERIAL

 

PLEASE ANSWER ALL THE QUESTIONS.  USE REVERSE SIDE IF NECESSARY. 

 

Title of Book, Film, Article, Etc. ______________________________

 

Author___________________ Hardcover___________ Paperback_________

 

Request initiated by__________________________ Date______________

 

Address__________________________________ Telephone______________

 

Complainant represents: 

________  Himself

________  Name of Organization

________  (Identify Other Group)

 

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

 

 

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

 

For what age group would you recommend this material? ___________

Is there anything good about this material?____________________________________

Have you inspected all the material?_______ 

Did you read the entire book? ______________________________________________________________________

Did you view the entire film? _______________________________________________

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

What do you believe is the theme of this material? _____________________________________ ________________________________

What would you like your school to do about this material? ______________________________________________________________________

 

____   Do not assign it to my student.

____   Withdraw it from all students as well as from my student.

____   Have its place within the curriculum reviewed. 

In its place, what material of equal literary or scholarly value would you recommend? ____________________________________________

 

RETURN COMPLETED FORM TO:                    

Superintendent of Schools Signed

__________________________                          _____________________________

Adoption Date:  9/19/17