* 1. Full Name:

* 2. Title/Role:

* 3. School District:

* 4. Address 1:

* 5. Address 2:

* 6. City:

* 7. State:

* 8. Zip:

* 9. Country:

* 10. Province:

* 11. Office Phone:

* 12. Home Phone:

* 13. Cell Phone (optional):

* 14. Fax:

* 15. Email:

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

* 17. Grade Level(s):

* 18. What specifically did the challengers find objectionable?

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

* 20. Were options for a reading substitute given?

* 21. Local support from English Department Head?

* 22. Local support from Principal?

* 23. Local support from Superintendent?

* 24. Local support from School Board?

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

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

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

* 28. Other organizations consulted?

* 29. Additional comments/concerns/circumstances?

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