CITIZEN’S CHALLENGE OF EDUCATIONAL MEDIA FORM

Type of Material: ___ Book ___ Magazine/Periodical ___ Film ___ Recording
                           ___ Software ___ Other (Please specify)

Author (if known)________________________________________________________________

Title ______________________________ Publisher____________________________________

Person making complaint___________________________________________________________
                                               Street
Telephone_______________ Address ______________________Town_____________________

Complainant represents: ___ Himself/herself
                                     ___ Organization___________________________________
                                     ___ Other group___________________________________

1. To what portion of the material do you object? (Please be specific, cite pages, scenes, etc.)
    _____________________________________________________________________

2. What do you feel might be the negative result of reading/viewing/hearing this material?
    _____________________________________________________________________

3. For what age group would you recommend this material?__________________________

4. Is there anything good about this material?_____________________________________

5. Did you read/view/hear all of the material? ______ If not, what parts did you read/view/ hear?
    _______________________________________________________________________

6. Are you aware of the professional reviews/judgment of this material?____________________

7. What do you believe is the theme and/or intention of this material?______________________

8. What would you like the school to do about this material?
    ___ Do not assign it to my child.
    ___ Do not assign it to any students.
    ___ Withdraw it from the library/instructional program.
    ___ Refer it to the Educational Media Review Committee for evaluation.

9. In its place, what material would you recommend?_____________________________________
    ___________________________________________________________________________



_____________________________                                     __________________________
Signature of Complainant                                                         Date

DATE ADOPTED: July 1, 2003