KEC-E ©

EXHIBIT

PUBLIC  CONCERNS / COMPLAINTS
ABOUT  INSTRUCTIONAL  RESOURCES

CITIZEN'S REQUEST FOR RECONSIDERATION
OF INSTRUCTIONAL MATERIAL

Author     ______________ Hardcover ____ Paperback _____ Other media _____

Title ___________________________________   Copyright date __________

Publisher (if known) ______________________________________________

Request initiated by__________________________  Telephone ___________

Address _______________________________________________________

Complainant's E-mail address ______________________________________

Complainant
represents:     ◻ himself or herself

                       ◻ (name organization):  ______________________________

                       ◻ (identify other group):  _____________________________

Please  use  the  reverse  side  for  additional 
space  or  comments

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

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

For what age group would you recommend this material?

What do you feel is good about this material?

Did you review the entire material?______   What parts?

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

What do you believe is the theme of this material?

Are you aware of the instructional purpose in using this work?

What would you like the District to do about this material?

◻ Do not assign or recommend it to my child (children).
◻ Do not assign it to students.
◻ Withdraw it from all patrons of the library.
◻ Refer it to an official committee for reevaluation.

In its place, what material of equal literary quality would you recommend that would convey as valuable a picture and perspective?

________________________________________     ___________________
Signature of complainant                                               Date