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Title ______________________________________________________________

Author ________________________

Type of Material __________________

Publisher __________________________________________________________

Request initiated by ________________________________________________

Telephone _____________

Address __________________________________

Complainant represents

□ Himself/Herself

□ Organization _________________________

□ Identify other group _________________

1. To what in the work do you object? (Please be specific; cite pages or selections)

________________________________________________________________________

________________________________________________________________________

2. Did you read/view the entire work? _____ If not, what pages or sections?

_______________________________________________________________________

3. Are you aware of the educational purpose of using this work?

_______________________________________________________________________

4. What do you believe is the theme or purpose of this work?

________________________________________________________________________

5. What would you prefer the school do about this work? (Please check all that apply)

□ do not assign or recommend it to my child

□ withdraw it from all students

□ send it to Review Committee for re-evaluation

Signature of Complainant _________________________ Date ______________