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