Request for Review of Instructional Materials

This mach form is used when there is a concern about a classroom assignment or student resources within a lesson in the existing curriculum and instructional materials.

Request Initiated by Request Initiated by First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Contact Phone Contact Phone - ### - ### ####
Which course (subject/grade level) was the material assigned?
Have you worked with the school where the materials were assigned and expressed your concern?

Have you worked with the school where the materials were assigned and expressed your concern? Yes No
If no, you will need to reach out to the school administrator to request a conference to discuss your materials challenge.
If yes, please list the date of the conference, the name of the staff present and describe the outcome of the conference. If you have supporting materials, please upload them below AND complete the remainder of the form.
Student's School and Grade Level if Applicable
Upload artifacts from school level conference.

Attach Files
Please select the type of material

Please select the type of material Textbook Non-Print material Other
Title/ISBN, Subject, Publisher
The following questions must be answered by the parent of a currently enrolled Pasco student or a resident of Pasco County, who has read, viewed, or listened to the instructional material in its entirety.

What is objectionable about the material? (Please be specific, cite pages, chapters etc.)
If sufficient space is not provided, attach additional sheets.
(Please sign your name to each additional attachment.)

Attach Files
What negative impact, if any, do you feel would result from students using this material?
What aspects of this material did you consider appropriate for student use?
Would you care to recommend an alternative to this instructional material that addresses the same content standards in the same format?
Name of Complainant Name of Complainant First Last
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Request for Review of Instructional Materials

Request for Review of Instructional Materials

If no, you will need to reach out to the school administrator to request a conference to discuss your materials challenge.