Form H311F: Challenge of Instructional Materials
Type of Material: ____ Book ____ Magazine/Periodical ____ Film ____Recording
____ Software ____ Other (Please specify) __________________
Author (if known) ________________________________________________________
Publisher (if known) ______________________________________________________
Person making complaint: __________________________________________________
Telephone ____________ Address _________________________ Town ____________
Complainant represents: ___ Him/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 and/or 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
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