# IJJ-E (FORM)- CITIZEN’S CHALLENGE OF EDUCATIONAL MEDIA FORM

**CITIZEN’S CHALLENGE OF EDUCATIONAL MEDIA FORM**

---

Type of Material:

<span style="text-decoration: underline;">\_\_</span> Book

\_\_ Magazine/Periodical

\_\_ Film/DVD

\_\_ Audio Recording

\_\_ Software | Developer (*if known*): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_ Other (Please specify):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Author/Developer (*if known*): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Publisher (*if known*): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Person making complaint: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Complaint represents:

\_\_ Self

\_\_ Organization/Group (Please name): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. Identify any particular sections to which 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\. Did you read/view/hear all of the material? YES or NO If not, what parts did you read/view/hear?

5\. What are the positive aspects of this material?

6\. Please identify any professional review/judgments of this material that you have read.

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 to any students.

\_\_ Withdraw it from the library and/or instructional program.

\_\_ Refer it to the Educational Media Review Committee for evaluation.

---

Signature of Complainant

---

Date

#### Cross Reference:

- [IJJ - Selection of Educational Materials](https://documentation.cape.k12.me.us/books/board-policies/page/ijj-selection-of-educational-materials)

#### Adopted:

- September 10, 2013

#### Reviewed/Revised:

- June 11, 2024