DENVER PUBLIC SCHOOLS



DENVER PUBLIC SCHOOLS

REQUEST FOR RECONSIDERATION OF BOOKS AND MATERIALS

DATE OF REQUEST: _________________

TYPE OF MATERIAL (BOOK, TEXTBOOK, VIDEO):__________________________

TITLE: _________________________________________________________________

AUTHOR: ______________________________________________________________

COPYRIGHT DATE: ________________ PUBLISHER: _________________________

REQUEST INITIATED

BY (NAME): ____________________________________________________________

TELEPHONE: _________________________ EMAIL: __________________________

ADDRESS: ________________________________________ CITY: _______________

STATE: _____________________ ZIP CODE: _________________________________

COMPLAINANT REPRESENTS:

SELF _____________________________

ARE YOU THE PARENT OR GUARDIAN OF A DPS STUDENT? YES ________ NO________

IF YES, WHAT GRADE LEVEL________________________________

OTHER (NAME OF ORGANIZATION/GROUP) _______________________________

1. Did you personally read, listen to, or view the entire work?

YES_________ NO________

If NO, please indicate what pages or sections of the challenged work you did read, listen to, or view. Please indicate by page number or section.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. Is this item part of a series or set? YES________ NO________

If YES, did you examine other items in the series or set? ________________

3. To your knowledge, was this resource

_____ assigned in the classroom

_____ recommended to your child

_____ part of the school library or classroom collection

_____ used by the entire school

4. Was your child required to use this resource? YES _____ NO _____

If YES, did you request an alternate resource for your child? YES____ NO____

5. Describe what prompted your concern about this resource. Please be specific in your references (page numbers, scenes, illustrations, content, etc).

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(Please attach additional information if appropriate.)

6. What of value is there in this work?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

7. What do you feel might be the result of reading (listening to or viewing) this work?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

8. For what age group would you recommend this work? ________________________

9. Are you aware of the teacher’s purpose in using this work? ____________________

10. Are you aware of the librarian’s intent of including this work in the school collection?

________________________________________________________________________

11. What would you prefer the school do about this resource?

__________ Use with professional guidance (i.e., teacher or librarian)

__________ Use with parental permission

__________ Do not assign it to my child

__________ Place resource at a higher grade level

__________ Send resource back to the staff selection official for reevaluation

__________ Withdraw it from all students

1)Return Completed Form to Principal.

2) Mail Copy of Form to: Director, Library Services

Educational Technology & Library Services

Denver Public Schools

1330 Fox St, Suite 300S

Denver, CO 80204

_______________________________________________________

Signature of Complainant

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