Skip To Main Content

KEC-E, Public Complaint About Instructional Materials

KEC-E, Public Complaint About Instructional Materials

Download PDF

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.)

  1. Did you read, view, or listen to the material in its entirety? _____________________
  2. Where is the material being used? Classroom ____ Library ____
  3. If it is being used in a classroom, please provide the following information:
    Grade _____ Name of class or subject ___________________________________
    Teacher _________________________________________
  4. Are students required to use the material? Yes ____ No ____ I don’t know _______
  5. Have you read reviews of this material by reputable sources? If so, please list sources.
    _______________________________________________________________
  6. To what do you object? (Please be specific. Cite pages or particular sequences of material.)
    _______________________________________________________________
  7. What do you believe is the theme or purpose of this material?
    _______________________________________________________________
  8. What do you feel might be the result of a student using this material?
    _______________________________________________________________
  9. Would you recommend this material for a different age group?
    _______________________________________________________________
  10. What other materials of the same subject and format would you recommend?
    _______________________________________________________________
  11. 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

______________________________________
Date

Please return completed form to the school principal.

(Principal will send copies of completed form to Director of Curriculum and to Media Services.)

Revision History

  • Revised Fall 2003