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Request For Review of Library or Instructional Materials
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* Indicates required question
School
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Johnson Elementary
Lexington Elementary
Scottsburg Elementary
Vienna-Finley Elementary
Scottsburg Middle
Scottsburg High
Early Learning Academy
Date:
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Your answer
Complainant's Name
*
Your answer
Complainant's Address
*
Your answer
Complainant's Phone Number
*
Your answer
Complainant Represents (Self, Organization, or Other)- Please identify in the answer area below and if an organization or other, identify a group.
*
Your answer
Type of Material in Question
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Book
Video
Other:
Title and Author (if book)
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Your answer
Publisher and Date of Publication
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Your answer
I have read, viewed, or listened to the complete work.
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Yes
No
Required
How did the student obtain access to the material?
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Free Choice/Free Selection
Class Assignment
Received from a friend/classmate
Other:
Is this material part of a series?
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Yes
No
Clearly state what is objectionable and why you feel it is objectionable. Be specific by including page numbers, timestamps, etc...
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Your answer
In your opinion, are there sections of the material that are appropriate? If yes, please share examples of those appropriate sections.
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Your answer
Did you read any reviews of the material?
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Yes
No
If yes to the above question, please share which reviews you read. If you did not, please put N/A in the response.
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Your answer
List any and all school personnel with whom you have discussed this material and your concerns.
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Your answer
What are your suggestions in regards to what needs to be done with the material in question?
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Have it reviewed and reevaluated for its appropriateness
Continue its use, but encourage my child to use alternative material
Withdraw it from the library circulation and classroom use
Other:
Required
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