Patrons Request for Reconsideration of Work
- Author, composer, producer, artist, etc.
- _____________________________________
- Title:
- _____________________________________
- Publisher:
- _____________________________________
- Request initiated by:
- _____________________________________
- Home address:
- _____________________________________
- City:
- _____________________________________
- State:
- _____________________________________
- Zip:
- _____________________________________
- Home Phone:
- _____________________________________
- Work Phone:
- _____________________________________
- Complaint represents:
- Himself/Herself:
- _____________________________________
- Organization:
- _____________________________________
- If an organization, in what capacity do you represent them?
- ___________________________________________________________
-
1. To what in the work do you object? Please be specific, cite exact parts:
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- 2. What do you feel might be the result of reading, viewing, or listening to this work?
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
3. What of value is there in this work?
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- 4. For what age group would you recommend this work?
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- 5. Did you read, view, or listen to the entire work?
- ___________________________________________________________
- 6. What pages or sections?
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- 7. Are you aware of the judgment of this work by critics?
- ___________________________________________________________
- 8. Are you aware of the teachers purpose in using this work?
- ___________________________________________________________
- 9. What do you believe is the theme or purpose of this work?
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- 10. What would you prefer the school to do about this work?
- ________
- do not assign or recommend it to my child
- ________
- withdraw it from all students use
- 11. In its place, what work of equal value would you recommend that would convey as valuable of picture and perspective of a society or set of values.
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- ___________________________________________________________
- Signature:
- ______________________________________
- Date:
- ______________________________________
**Attach extra pages if needed to complete statements.
Reconsideration Request form
Committee Report form
Acceptable Use Agreement
Acceptable Use Permission Slip
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