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 _________