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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