Form: Request for Reconsideration of Questioned Materials

SCHOOL INFORMATION School Name: __________________________________________________________________________________________________ School Address: __________________________________________________________________________________________________ School Principal: __________________________________________________________________________________________________ School Media Specialist: __________________________________________________________________________________________________ School contact number: __________________________________________________________________________________________________

complainant INFORMATION Request initiated by: __________________________________________________________________________________________________ Date of compalint filed: __________________________________________________________________________________________________ Address: __________________________________________________________________________________________________ Contact number: __________________________________________________________________________________________________ complainant represents: __________________________________________________________________________________________________

BOOK INFORMATION Author: __________________________________________________________________________________________________ Title: __________________________________________________________________________________________________ Publisher info: __________________________________________________________________________________________________ Hardcover:__________________ Paperback:______________ (check one) Please attach your typed responses to the questions below and return with this form: To what in the book or instructional material do you object? Please be specific. What do you feel might be the effect on the student of reading this book, or using this instruction. 2005