Name of Person Completing This Form __________________________________________
(or “Materials Review Committee”)
Telephone Number ____________________________________________________________
Address __________________________________________________________________
City, State, Zip ____________________________________________________________
Please check type of instructional material to be reviewed:
_____ Book ____ Film/Video/DVD _____ Periodical
_____ Pamphlet _____ Cassette _____ Other
Title ________________________________________________________________________
Author __________________________________________________________________
Publisher or Producer ______________________________________________________
The following questions are to be answered after the complainant (or “Materials Review Committee”) has read, viewed, or listened to the instructional material in its entirety. If sufficient space is not provided, please attach additional sheets. (Please sign your name to each additional attachment.)
1. To what in the material do you object? (Please be specific—site pages, etc.)
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
2. What do you believe is the theme or purpose of this material?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
3. Why do you object?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
4. What do you feel might be the negative result of a student using this material?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
5. For what age group would you recommend this material?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
over ?
6. Do you feel there is anything good in this material? Please comment.
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
7. Would you care to recommend other school library material of the same subject and format to replace the material in question?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
8. Do you recommend the continuation of using the material in question? Why or why not?
______________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
________________________________________________ ________________________
Signature of Complainant (or “Materials Review Date
Committee” Member)
Please return completed form to Building Principal
(or to District Administrator if form is being completed by “Materials Review Committee”)
APPROVED: January 22, 2004
12/21/2004 pw