Author:_______________________________________________________________________
Type of Instructional Material:_____________________________________________________
Title:_________________________________________________________________________
Publisher (if known):____________________________________________________________
Request initiated by:_______________________________________Telephone:_____________
Street Address:_________________________________________________________________
City:____________________Zip Code: _________________
Curriculum area and grade of item:__________________________________________________
Complainant represents:___________________________________________________________
Please circle : self (name of organization) (identify other group)
1. To what in the item do you object? (Please be specific)
2. What do you feel might be the result of using this item?
3. For what age group would you recommend this item?
4. Do you feel there is any value in this item?
5. Did you examine the entire item?What parts?
6. Have you had an opportunity to discuss the proposed use of
this item with a staff member?
__________________________________________________Date____________________
Signature of Complainant
Please send this request to:
Dale R. Rauenzahn
Executive Director
Office of Student Support Services
Baltimore County Public Schools
9610 Pulaski Park, Suite 219
Towson, MD 21220
You will receive a response from: The Department of Curriculum
and Instruction