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: ____________________________
12/90
Exhibit ATASCADERO UNIFIED SCHOOL DISTRICT
version: November 2, 1999 Atascadero, California