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Harrison County Schools

Request for Reconsideration of Materials


SCHOOL: _____________________________________________________________
Format of Material: _____________________ Author: __________________________
Title: _____________________________ Publisher/Producer: ___________________
Request initiated by: _________________________ Telephone: __________________
Address: ____________________________ City/State/Zip: ______________________
Complainant represents: ____Himself
____ Organization (Name) ___________________________
____ Other Group (Name) ___________________________
The following questions are to be answered after the complainant has read, viewed, or
listened to the material in its entirety. If sufficient space is not provided, attach additional
sheets. Please sign each additional attachment.
What do you object to in the material? (Please be specific.)
______________________________________________________________________
______________________________________________________________________
What do you believe is the theme or purpose of this material?
______________________________________________________________________
______________________________________________________________________
What do you feel might be the result of a student using this material?
______________________________________________________________________
______________________________________________________________________
For what age group would you recommend this material?
______________________________________________________________________
______________________________________________________________________
Is there anything good in this material? _______ Please comment:
______________________________________________________________________
______________________________________________________________________
Would you care to recommend other instructional material of the same subject and
format?
______________________________________________________________________
______________________________________________________________________

__________________________________
Signature of Complainant
Reviewed by Board:

_____________________
Date

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