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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 District’s educational purpose for 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 ______________