Library Media Materials Challenge

This form is for use by a Pasco County Resident and/or legal guardian of a Pasco County Schools student who wishes to challenge the placement of books, resources or materials available in school library media centers, in conjunction with district policies and procedures.

Challenge initiated by: Challenge initiated by: First Last
Address Address
Street Address City State / Province / Region Postal / Zip Code
Email
Contact Phone Contact Phone - ### - ### ####
I am a: (select one of the following)

I am a: (select one of the following) Pasco County School's Student (18 or older) Pasco County Schools Employee Parent/Guardian of a Pasco County Schools student Resident in Pasco County
Have you already worked through the school level conference with the building administrator?

Have you already worked through the school level conference with the building administrator? Yes No* I am not affiliated with a specifc school, I am a Pasco County resident seeking to challenge material(s)
*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.
Upload artifacts from school level conference.

Attach Files
Please respond to the following questions.
Please select the type of material

Please select the type of material Book (print or eBook) Periodical (newspaper, magazine, etc.) Video/Streaming Media Software Application or other education technology Electronic Information Database Other Other
Title/Author, ISBN, Subject, Publisher or Producer, Copyright Date
For which grade level is this material used?
School(s) where the material is located:
Where is this material located? (Check all that apply)

Where is this material located? (Check all that apply) Library Media Center Classroom Library Reading List Other Other
Basis for the Objection

Basis for the 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.
Have you read, seen, viewed, and/or listened to this material in its entirety?

Have you read, seen, viewed, and/or listened to this material in its entirety? Yes No
What brought this material to your attention?
What do you believe is the main idea of this material?
Identify the portion of the material objected to and state your reasons why. (You must be specific and provide page numbers, sections, or timestamps, as appropriate.)
If sufficient space is not provided, attach additional sheets.
(Please sign your name to each additional attachment.)

Attach Files
What do you feel would be the negative impact that might result from the use of this material?
Have you read any expert reviews relating to this material? If so, please describe.
Were students required to read or view the material? Was an alternative to the material provided at parent or student request?
Is there any age or grade you would recommend this material? If yes, please specify:
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 access to certain grade levels:
Additional comments
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

Library Media Materials Challenge

Library Media Materials Challenge

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

Please respond to the following questions.