Amended: 2-25-86
APPENDIX A
PATRON'S REQUEST FOR RECONSIDERATION OF A WORK
(Attach extra pages if needed to complete statements)
Author, composer, producer, artist, etc.________________________________________
Title____________________________________________________________________
Publisher (if known)_______________________________________________________
Request initiated by________________________________________________________
Telephone_________________ Address_______________________________________
Complainant represents: _____himself
_____Name of organization_________________________________________________
_____Identify other group__________________________________________________
1. To what in the work do you object? Please be specific, cite exact parts:_________
__________________________________________________________________
__________________________________________________________________
2. What of value is there in this work?_____________________________________
__________________________________________________________________
__________________________________________________________________
3. What do you feel might be the result of reading, viewing, or listening to this work?
__________________________________________________________________
__________________________________________________________________
4. For what age group would you recommend this work?______________________
5. Did you read, view, or listen to the entire work?___________________________
What pages or sections?______________________________________________
6. Are you aware of the judgment of this work by critics?______________________
7. Are you aware of the teacher's purpose in using this work?___________________
8. What do you believe is the theme or purpose of this work?___________________
__________________________________________________________________
__________________________________________________________________
9. What would you prefer the school do about this work:
____Do not assign or recommend it to my child.
____Withdraw it back from all students.
____Send it back to the proper department for reevaluation.
10. In its place, what work of equal value would you recommend that would convey as valuable a picture and perspective of a society or set of values?________________
__________________________________________________________________
__________________________________________________________________
__________________________________________
Signature of the complainant
__________________________________________