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

CITIZEN’S CHALLENGE OF EDUCATIONAL MEDIA FORM 

 

 Type of Material: 

 __ 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 

 

 Adopted: 

 

 September 10, 2013 

 

 Reviewed/Revised: 

 

 June 11, 2024