IJJ-E Challenge of Instructional Materials Form
NEPN/NSBA Code: IJJ-E 

CHALLENGE OF INSTRUCTIONAL MATERIALS FORM 

Type of Material: ____     Book ____     Magazine/Periodical ____     Film ____    Recording ____ Software ____ Other (Please specify) __________________

Author (if known) ________________________________________________________________________

Title __________________________________________________________________________________

Publisher (if known) ______________________________________________________________________

Person making complaint: _________________________________________________________________

Telephone ____________    Street  Address _________________________     Town __________________

Complainant represents: ________ Him/Herself

                                        ________ Organization _____________________________________

                                        ________ Other group ______________________________________

1. To what portion of the material do 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. Is there anything good about this material? ________________________________________

5. Did you read/view/hear all of the material? ________ If not, what parts did you read/view/ hear?

_____________________________________________________________________________

6. Are you aware of the professional reviews/judgment of this material? ____________________

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 it to my child.

        _______ Do not assign it to any students.

        _______ Withdraw it from the library and/or instructional program.

        _______ Refer it to the Educational Media Review Committee for evaluation.


9. In its place, what material would you recommend? _________________________________

___________________________________________________________________________

__________________________________             _____________________
Signature of Complainant                                       Date


Adopted:     November 12, 2003
Revised:     November 9, 2010

M.S.A.D. #4