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