FORM B Policy Ref. 606.02
ELKHORN PUBLIC SCHOOLS
REQUEST FOR RECONSIDERATION OF INSTRUCTIONAL MATERIAL
Materials: Book ____ Film ____ Filmstrip ____ Record ____ Other ____
Author ____________________________________________
Title ____________________________________________
Publisher or producer (if known) ____________________________________________
Request initiated by ____________________________________________
Telephone_____________________ Address _________________________
Do you represent Yourself ____ Other group or organization ____
PLEASE RESPOND TO THE FOLLOWING. USE ADDITIONAL PAPER IF NEEDED.
1. Have you read/viewed this material in its entirety?
2. To what in the material do you object? (Please be specific, cite pages.)
3. What do you feel might result from the use of this material?
4. What would you like your school to do about this material?
5. In its place, what material would you recommend?
6. Do you desire to meet with the Materials Review Committee to discuss this material? Yes____ No ____
____________________________________________
Signature of Complainant
____________________________________________
Date
PLEASE SUBMIT THIS FORM TO THE BUILDING PRINCIPAL