This form replaced IJJ-E Procedures for Challenges to Educational reform and IJJ-D-RA challenges to educational resources Form                                                                                          NEPN/NSBA Code: IJJ-E

ADOPTED 6/16/10

 

CHALLENGE OF INSTRUCTIONAL MATERIALS FORM

 

Type of Material: ____ Book ____ Magazine/Periodical ____ Film ____Recording

                        ____ Software ____ Other (Please specify) __________________

 

Author (if known) ________________________________________________________

 

Title ___________________________________________________________________

 

Publisher (if known) ______________________________________________________

 

Person making complaint: __________________________________________________

                                                Street

Telephone ____________ Address _________________________ Town ____________

 

Complainant represents:          ___ Him/herself

                                                ___ Organization ________________________

                                                ___ Other group ________________________

 

1.         To what portion of the material do you object? (Please be specific, cite pages, scenes, etc.) ________________________________________________________

 

2.         What do you feel might be the negative result of reading/viewing/hearing this material? __________________________________________________________

 

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

 

4.         Is there anything good about this material? _______________________________

 

5.         Did you read/view/hear all of the material? ________            If not, what parts did you read/view/ hear? ____________________________________________________

 

6.         Are you aware of the professional reviews/judgment of this material? __________

 

7.         What do you believe is the theme and/or intention of this material? ____________

 

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

            ___      Do not assign it to my child.

            ___      Do not assign it to any students.

            ___      Withdraw it from the library and/or instructional program.

            ___      Refer it to the Educational Media Review Committee for evaluation.

 

9.         In its place, what material would you recommend? ________________________

            __________________________________________________________________

 

__________________________________                                 _____________________

Signature of Complainant                                                                  Date