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* 1. Date:

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* 2. Full Name:

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* 3. Title/Role:

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* 4. School District:

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* 5. Complete Contact Information:

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* 6. Challenged Work(s)/Method(s):

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* 7. Grade Level(s):

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* 8. What specifically did the challengers find objectionable?

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* 9. Does the district and/or school have a policy/procedure for responding to challenges to materials or methods?

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* 10. Were options for a reading substitute given?

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* 11. Local support from English Department Head?

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* 12. Local support from Principal?

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* 13. Local support from Superintendent?

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* 14. Local support from School Board?

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* 15. Has there been media coverage of the challenge?

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* 16. If there has been media coverage of the challenge, please explain below:

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* 17. What was the procedure/policy used by the teacher(s) for selection of the work(s) or method(s) challenged?

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* 18. Other organizations consulted?

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* 19. Additional comments/concerns/circumstances?

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