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 HART-RANSOM UNION SCHOOL DISTRICT
version: January 14, 2016 Modesto, California