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Atascadero USD |  E  1312.2  Community Relations

Complaints Concerning Instructional Materials   

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Citizen's Request For Reconsideration Of Instructional Materials

Date: ____________________

TITLE: ______________________________

AUTHOR: ___________________________

PUBLISHER: _________________________ DATE OF EDITION:_____________________

Request received by: ______________________ Title: _______________________________

Citizen's Name: ___________________________ Phone: ____________________________

Citizen Represents: Himself/Herself: ___________ Organization or Group: _________

Citizens are requested to respond to items 1-10 below using separate paper and attached the response to this form.

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: ____________________________



version: November 2, 1999 Atascadero, California