FORM C Policy Ref. 606.02

FORM C Policy Ref. 606.04

ELKHORN PUBLIC SCHOOLS
REQUEST FOR RECONSIDERATION OF MEDIA CENTER MATERIAL

Title: ____________________________________________

Author: _________________________________________

Publisher: ____________________________________________

Name of school where material is located:

_____________________________________________

Reconsideration Request initiated by:

____________________________________________

Telephone_____________________ Address _____________________________________________

PLEASE RESPOND TO THE FOLLOWING. USE ADDITIONAL PAPER IF NEEDED.

1. Have you read/viewed this material in its entirety (required)? _____ YES _____ NO

2. Identify those parts or aspects of the material to which you object. (Cite specific pages, passages or scenes.)

3. State your reasons for considering the material objectionable and what you believe would be the consequences of its use.

4. For what age group, if any, would you find this material appropriate?

5. Have you read professional reviews of this material? (see Selection Policy 606.03 for a list of professional review sources) _____ YES _____ NO

1. If yes, which ones?

6. What action are you requesting that the District take on this material?

____________________________________________
Signature of Complainant

____________________________________________
Date

PLEASE SUBMIT THIS FORM TO THE BUILDING PRINCIPAL