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.

Challenge initiated by: Challenge initiated by: First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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 Other Other
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* 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.
Student's School and Grade Level if Applicable
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/ISBN, Subject, Publisher
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 do you believe is the main idea of this material?
Please cite specific passages, pages, sequences, etc. State your reasons for objection to the cited passages.
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?
What action(s) would you prefer the school take on this material?
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.