Request for Review of Instructional Materials

This form must be used by a parent or resident of this county, in conjunction with district policies and procedures, to submit an objection to the school board for the following material:

1. Materials used in a classroom in the district, except for instructional materials as defined in s.1006.29(2), F.S. The process and forms to object to instructional materials can be found https://www.pasco.k12.fl.us/oll_documents/instructional-materials.

2. Materials made available to students in a school or classroom library.

3. Materials included on a school or classroom reading list.

4. Instructional Materials adopted and made available to students without the opportunity for public notice, review and hearing procedures by districts that implement their own instructional materials program under s. 1006.283, F.S

Section 1: Parent or Resident Information

Section 1: Parent or Resident Information Parent/guardian of a student Resident of this county
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 - ### - ### ####
Type of material

Type of material Book Non-Print material Other
Author(s)
Publisher or Producer
Copyright Date
Grade Level used:
Where is the material found:

Where is the material found: Media Center Classroom Library Reading List Other
Schools where material is found
ISBN, if available
Basis for your objection:

Basis for your objection: The material is pornographic. The material is prohibited under Section 847.012, F.S. The material depicts or describes sexual conduct as defined in Section 847.001(19), F.S The material is not suited to student needs and their ability to comprehend the material The material is inappropriate for the grade level and age group for which it is used
What brought this material to your attention?
Did you examine this material in its entirety

Did you examine this material in its entirety Yes No
If not, what sections did you examine? (if yes, type NA)
Identify the portion of the material objected to and why. (You must be specific and provide page numbers, sections, or timestamps, as appropriate. You may attach additional information that does not fit withing this form.)
Is there any age or grade you would recommend this material?

Is there any age or grade you would recommend this material? Yes No
If yes, please specify (if no, type NA):
Is there any value in this material?
What is your desired outcome for this material

What is your desired outcome for this material Remove or discontinue use of material Limit access to certain grade levels: Limit my child's access. Other
If sufficient space is not provided, attach additional sheets.
(Please sign your name to each additional attachment.)

Attach Files
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