West Side Union SD (Healdsburg) | E 1312.2 Community Relations
Complaints Concerning Instructional Materials
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 WEST SIDE UNION SCHOOL DISTRICT
version: November 8, 2007 Healdsburg, California