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NEPN/NSBA Code: IJJ-E MSAD #37 Citizen’s Challenge of
Educational Media Form
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Type of Material: |
___ Book |
___ Magazine/Periodical |
___ Film |
___ Recording |
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___ Software |
___ Other (Please specify) _________________________ |
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Author (if
known) ______________________________________________________________ Title _________________________________________________________________________ Publisher (if
known) _____________________________________________________________ Person making
complaint ______________________________ Telephone _________________ Street Address ____________________________ Town _______________________________ |
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Complainant represents: |
___ Him/herself ___
Organization ________________________________________ ___ Other group ________________________________________ |
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1. |
To what portion of the material do you
object? (Please be specific, cite pages, scenes, etc.) _______________________________________________________________________ |
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2. |
What do you feel might be the negative
result of reading/viewing/hearing this material? _______________________________________________________________________ |
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3. |
For what age group would you recommend this material? ___________________________ |
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4. |
Is there anything good about this material? _____________________________________ |
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5. |
Did you read/view/hear all of the
material? ____ If not, what parts did you read/view/
hear? _______________________________________________________________________ |
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6. |
Are you aware of the professional reviews/judgment of this material? __________________ |
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7. |
What do you believe is the theme and/or intention of this material? ____________________ |
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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. |
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9. |
In its place, what material would you
recommend? _______________________________________________________________________ _______________________________________________________________________ |
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____________________________________________________ ______________________ Signature of Complainant Date |
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Adopted: May 31, 2000
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