Request for Reconsideration of Instructional Resources
Date *
MM
/
DD
/
YYYY
Name of person making request *
Your answer
Phone Number *
Your answer
Address *
Your answer
Complainant represents *
himself/herself or organization
Your answer
Name of Organization if applicable
Your answer
Are you a parent of guardian of a student in this school? *
Child's Grade Level
if applicable
School which owns the item to be reconsidered *
Mooresville Graded School District
Title of Item *
to be reconsidered
Your answer
Format of Item
book, video, digital resource, ie.
Your answer
Author, Artist, Composer *
Your answer
Publisher/Producer
Your answer
Copyright Date
Your answer
How did you acquire this item? *
Your answer
Did you read, view, or listen to the entire item? *
If No, what parts did you review?
Your answer
Is this item part of a series or set? *
If Yes, did you examine other items in the series or set?
Which items?
Your answer
To what in the item do you object? *
(Please be specific: cite pages, frames, etc.)
Your answer
What do you feel might be the result of a student's reading, viewing, or listening to this item? *
Your answer
Are you aware of any evaluations of this item by authoritative sources? *
If Yes, did those sources agree with your opinion?
Please list the sources
Your answer
Do you want other persons in the community to determine the kind of materials your child may or may not use in school? *
Other Comments
Your answer
Once you are contacted by the school you may be asked to come in and sign your formal complaint *
Will this be an issue for you?
Submit
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