topleft CSBA.org >  Services >  Governance Technology > 

Perris Union HSD |  E  1312.2  Community Relations

Complaints Concerning Instructional Materials   

arrow Previous bar Next arrow

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 PERRIS UNION HIGH SCHOOL DISTRICT

version: May 17, 2006 Perris, California