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Elk Grove USD  |  E  1312.2  Community Relations

Complaints Concerning Instructional Materials   

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REQUEST FOR RECONSIDERATION OF BOOK/INSTRUCTIONAL MATERIALS

(The staff member will submit the request to the Principal or Director of Curriculum and Professional Learning)

Complainant's Name:_________________________________________________________

Complainant's Address________________________________________________________

Complainant's Phone Number__________________________________________________

Represents: (select one)

_____Self _____Organization (please specify) _____Other: (please specify)

Title of Book/Instructional Material:_____________________________________________

Author:____________________________________________________________________

Publisher:__________________________________________________________________

Did you read/view the entire book/film/instructional material? Yes_____ No_____

If not, what parts did you read? _________________________________________________

___________________________________________________________________________

What is the topic or theme of this book/film/instructional material?_____________________

___________________________________________________________________________

___________________________________________________________________________

To what in particular did you object? (Be specific; cite pages, etc.)_____________________

___________________________________________________________________________

___________________________________________________________________________

What do you feel might be the result of reading/viewing this book/film/instructional material?___________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

What would you like the school or the District to do about this book/film/instructional material? (check one)

_____Do not assign it to my child

_____Remove it from the total District program

_____Use only with parental permission

_____Restrict its use to:

_____Grades K-3 only

_____Grades 4-6 only

_____Grades 7-8 only

_____Grades 9-12 only

Comments: ________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Submitted to/Name of School:__________________________________________________

Signature of Complainant:_____________________________________________________

Date Request Initiated:________________________________________________________

Exhibit ELK GROVE UNIFIED SCHOOL DISTRICT

version: May 7, 1990 Elk Grove, California

revised: March 5, 2008

revised: August 19, 2019