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 ________________________________________
                
Telephone ________________

Street 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