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Request for Reconsideration of School Library Media Materials
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Email
*
Your email
Name of person making request
Your answer
Address
Your answer
Phone Number
Your answer
Email
Your answer
Complaint represents:
Self
Organization
Other group
Clear selection
Do you have a child in this school?
Yes
No
If yes, Grade:
Title of Item
Your answer
Type of media
Book
Video
Magazine
Other
Author/Artist/Composer
Your answer
Publisher/Producer if known
Your answer
How did you acquire this item?
Your answer
Did you read, view, or listen to the entire item?
Yes
No
Clear selection
If not, what parts?
Your answer
Is this item part of a series or set?
Yes
No
Clear selection
If yes, did you examine other items in the series or set?
Yes
No
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What do you believe are the theme and purpose of this item?
Your answer
To what in the item do you object? Please be specific, cite pages, frames, etc.
Your answer
Does this item have any redeeming features or values?
Yes
No
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If yes, please list them
Your answer
For what age or grade level would you recommend this item?
Your answer
What do you think 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?
Yes
No
Clear selection
If yes, please list them
Your answer
What would you like your school to do about this item?
Your answer
Other comments
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Date
MM
/
DD
/
YYYY
Provide electronic signature (Full name)
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