IMB-E1 Objection to Curriculum Topic or Material Form
NEPN/NSBA Code: IMB-E1 

OBJECTION TO CURRICULUM TOPIC OR MATERIAL FORM 

Student’s Name _________________________________________________ Date __________________

Grade ________________ Teacher’s Name __________________________________________________

Subject _______________________________________________________________________________

Request initiated by _________________________ Relationship to Student ________________________

Telephone # ______________________ State ______________ Zip Code _________________________

Complaint represents:

Self _________________________________________________________________________________

Name of Organization ___________________________________________________________________

Other Group __________________________________________________________________________


1. What topic(s) or material(s) are you concerned about? Be specific: cite pages, etc.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. What do you feel might be the result of reading, listening, or viewing this work?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

3. Did you read, listen, or view this entire work: _____________________________________________

4. What do you believe is the theme of this work? ___________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

5. What do you propose as an alternative to the material or topic for the child?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________


Signature of Complainant: _____________________________________________________________


Adopted:      December 11, 2001
Revised:      March 9, 2004
Reviewed:   November 2, 2010

M.S.A.D. #4