Date: ________________
TITLE: ____________________________________
AUTHOR: ___________________________________
PUBLISHER: ________________________________
DATE OF EDITION: __________________________
Request received by: ______________________
Title: ____________________________________
Citizen's Name: ___________ Phone: ________
Citizen Represents: Himself/Herself: Organization or Group:
1. To what do you object? (Please be specific: cite pages, tape sequence, video frame, and words)
2. What do you feel would be the result of reading/viewing this material?
3. For what age group would you recommend this material?
4. Did you read/view the entire selection?
5. If not, what percentage did you read/view, or what parts?
6. Is there anything good about this material?
7. What would you like the school to do about this material?
___ Do not assign it to my child.
___ Withdraw it from all students.
___ Re-evaluate it.
8. Are you aware of how this work has been assessed by literary critics?
9. What do you believe is the thesis of this work?
10. In its place, what work would you recommend?
_________________________________________
Signature of citizen
Action taken: _________ Date: ___________
Exhibit ALHAMBRA UNIFIED SCHOOL DISTRICT
version: December 9, 2003 Alhambra, California