CITIZEN’S REQUEST FOR RECONSIDERATION OF INSTRUCTIONAL MATERIALS

TYPE OF MATERIAL:

Book __________ Filmstrip __________ Film ____________

Other __________ Recording __________ Periodical ______
(Specify)

Author/Producer ______________________________________________________

Title __________________________________________________________________

Publisher (If Known) ________________________________________________

Request Initiated by: ________________________________________________

Telephone: __________ Address: ____________________________________

City: ________________ Zip Code: ____________________________________

COMPLAINANT REPRESENTS:

Himself/Herself __________ Name of Organization __________________

Identify Other Group ________________________________________________

1. To what do you object? (Please be specific; cite pages or section). ______

________________________________________________________________________

________________________________________________________________________

2. What do you feel might be the result of using this material?
________________________________________________________________________

________________________________________________________________________

3. For what age group would you recommend this material? ____________


4. Is there anything good about this material? ________________________

________________________________________________________________________

5. Did you read or view the entire item? ______________________________

If not, which parts? __________________________________________

6. Are you aware that this material has been judged by professional

educators? ____________________________________________________________

7. What do you believe is the purpose of this material? ____________

________________________________________________________________________

8. What would you like your school to do about this material?

Do not assign it to my child. __________

Withdraw it from all students. __________

Send it back to the principal for re-evaluation. __________

9. In its place, what materiel would you recommend that would convey as

valuable a picture and perspective of our civilization?

________________________________________________________________________

________________________________________________________________________



________________________________ ______________________________
Signature of Complainant Date

Moffat County School District RE-1 Regulation 6613