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H311F - Materials Challenge Form

Form H311F: Challenge of Instructional Materials

 

Type of Material:   ____  Book   ____  Magazine/Periodical   ____ Film   ____Recording

                                 ____  Software    ____  Other (Please specify)  __________________

Author (if known)  ________________________________________________________

Title  ___________________________________________________________________

Publisher (if known)  ______________________________________________________

Person making complaint:  __________________________________________________

                                                Street

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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