KEC-E, Public Complaint About Instructional Materials
Citizen’s Request for Review of Instructional Materials
School in which the material is being used:
Your Name (please print): __________________________________________________________________
Telephone #: _______________ Address: __________________________________
Complainant represents: Self _____ Organization/Group _____ (Name of group) ________
Do you have a student who attends the school listed above? Yes ____ No ____
Please check the type of material in question:
Book _______ Video ______ Kit _____________ Magazine ____ Audio ______ Other____________ Pamphlet ____ Software ____
Title of material:
Author/Distributor: ______________________________________ Copyright Year: _______
The following questions are to be answered after the complainant has read, viewed or listened to the material. If sufficient space is not provided, attach additional sheets. (Please sign your name to each additional attachment.)
- Did you read, view, or listen to the material in its entirety? _____________________
- Where is the material being used? Classroom ____ Library ____
- If it is being used in a classroom, please provide the following information:
Grade _____ Name of class or subject ___________________________________
- Are students required to use the material? Yes ____ No ____ I don’t know _______
- Have you read reviews of this material by reputable sources? If so, please list sources.
- To what do you object? (Please be specific. Cite pages or particular sequences of material.)
- What do you believe is the theme or purpose of this material?
- What do you feel might be the result of a student using this material?
- Would you recommend this material for a different age group?
- What other materials of the same subject and format would you recommend?
- What is your request in regard to this material?
- Do not assign it to students at this grade level __________
- Withdraw it from use at the school __________________
- Require parental permission for use _________________
- Refer it to an official committee for evaluation __________
Signature of complainant
Please return completed form to the school principal.
(Principal will send copies of completed form to Director of Curriculum and to Media Services.)
- Revised Fall 2003