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Gilroy USD |  E  1312.2  Community Relations

Complaints Concerning Instructional Materials   

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REQUEST FOR RECONSIDERATION OF INSTRUCTIONAL MATERIALS

This form is for use only by district employees, district residents, or parents/guardians of children enrolled in a district school to challenge the content or use of an instructional material. For complaints regarding sufficiency of instructional materials, please use the Williams Uniform Complaint Procedure complaint form.

Date:______________________

Name of person filing complaint:________________________________________________

Anonymous complaints will not be accepted.

Group represented (if any):____________________________________________________

Phone:__________________________ E-mail address, if any:________________________

Address:___________________________________________________________________

Material Being Challenged:

Title: ______________________

Author: ______________________

Publisher: ______________________ Date of Edition: ______________________

Name of school/classroom material was used: _____________________________________

1. Please specifically state the nature of your concern or objection and identify your objection by page, tape sequence, video frame, or words, as appropriate. You may use additional pages if necessary.

2. Did you read/view the entire selection?

3. For what age group would you recommend this material?

4. If not, what percentage did you read/view, or what parts?

5. What do you feel might be the result if a student reads/views this material?

6. What would you like the school to do about this material?

___ Do not assign it to my child

___ Withdraw it from all students

___ Reconsider it

Signature of complainant

For District Use:

Request received by: ______________________ Date: ______________________

Title:______________________________________________________________________

Action taken: ______________________ Date: ______________________

Exhibit GILROY UNIFIED SCHOOL DISTRICT

version: November 20, 2008 Gilroy, California