Policy Code: 3210A


Name of Person making request __________

Telephone ___ Address ________

Complainant represents: _ Himself Organization (name) ____ __ Other Group (name) ____

Name of School owning challenged material ______

Title of item challenged ___________

Type of media (book, film, recording, etc.) _______

Author/artist/composer/producer __________

Publisher/producer (if known) ____________

  1. What do you believe are the theme and purpose of this item? ___

  1. For what age group would you recommend this item? ________

  2. What do you feel might be the result of a student’s reading, viewing, or listening to this

item? ____________

  1. To what in this item do you object? (Specify/cite: pages, photos, frames, etc.)

  1. Is there anything good about this item? Explain ______

  1. Did you read, view, or listen to the entire item? ___ If not, what parts? ______

Avery County Schools Policy Page 1 of 2 Policy Code: 3210A

  1. Are you aware of the evaluation of this item by authoritative sources? _______

  2. What would you like your school to do about this item? __ Do not assign it to any child _ Withdraw it from all students as well as your child. Refer it to the media coordinator’s office for reevaluation. ___ Make it available only to those who wish to use it.

  3. In its place, what item of equal educational quality would you recommend to convey as valuable a concept and perspective of the subject covered by this item?


Avery County Schools Policy Page 2 of 2