Name of person making request                                                                                              

Telephone _____________ Address __________________________________________

Complainant represents:

• himself/herself ______
• organization______ (if yes, please name) _____________________________
• other group ______ (if yes, please identify) ___________________________

Name of school owning challenged material ____________________________

Do you have a child in this school? ______  Grade ________

Title of item ___________________________________________________________

Type of media: [book, film, filmstrip, video, etc.] _________________________

Author / artist / composer / etc. _______________________________________

Publisher / producer, if known ________________________________________

How did you acquire this item? ________________________________________

Did you read, view, or listen to the entire item? ______

If not, what parts? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Is this item part of a series or set? ______

If yes, did you examine other items in the series or set? ______

What do you believe are the theme and purpose of this item?   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

To what in the item do you object? Please be specific; cite pages, frames, etc.   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Does this item have any redeeming features or value? ______

If yes, please list them   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 

For what age or grade level would you recommend this item? ____________

What do you think might be the result of a student’s reading, viewing, or listening to this item?   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Are you aware of any evaluations of this item by authoritative sources? ________

If yes, did those sources agree with your opinion? ________

Please list the source(s)   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

What would you like the school to do about this item?

• ______  Not assign it to your child.
• ______  Not assign it to any child.
• ______  Make it available only to those who wish to use it.
• ______  Refer it to the Media Advisory Committee for re-evaluation.
• ______  Withdraw it from the school library collection.
• ______  Other: please specify   ___________________________________________________________________________ ___________________________________________________________________________

What would you suggest that the school purchase in lieu of this item?   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Why is your recommendation a better choice?   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Other comments:   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Signature of Complainant _____________________________ Date ________