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Hope ESD  |  E  1312.2  Community Relations

Complaints Concerning Instructional Materials   

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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: __________________


version: June 10, 2019 Santa Barbara, California