Petaluma City Schools | E 1312.2 Community Relations
Complaints Concerning Instructional Materials
CITIZEN'S REQUEST FOR RECONSIDERATION OF INSTRUCTIONAL MATERIALS
PUBLISHER: DATE OF EDITION: ________________________
Request received by ________________________Title ________________________
Citizen's Name: ________________________Phone: ________________________
Citizen Represents: Himself/Herself: ________________________ Organization or Group:
1. To what do you object? (Please be specific: cite pages, tape sequence, video frame, and words)
2. What do you feel would be the result of reading/viewing this material?
3. For what age group would you recommend this material?
4. Did you read/view the entire selection?
5. If not, what percentage did you read/view, or what parts?
6. Is there anything good about this material?
7. What would you like the school to do about this material?
( Do not assign it to my child.
( Withdraw it from all students.
( Re-evaluate it.
8. Are you aware of how this work has been assessed by literary critics?
9. What do you believe is the thesis of this work?
10. In its place, what work would you recommend?
Signature of citizen
Action taken: ________________________ Date: ________________________
Exhibit PETALUMA CITY SCHOOLS
version: June 25, 2002 Petaluma, California