Curriculum Concern Report Form

	Today's Date*

	Name*

	Please indicate your relationship to MCCSC.*
	--Please Select--ParentTeacherStudentCommunity MemberOther

	Phone Number and Email Address*

	At which school was the curriculum concern first identified?*
	--Please Select--Arlington HeightsBinfordChildsClear CreekFairviewGrandviewHighland ParkLakeviewMarlinRogersSummitTempletonUnionvilleUniversityBatchelorJackson CreekTri-NorthThe Academy of Science and EntrepreneurshipBloomington Graduation SchoolBloomington High School NorthBloomington High School SouthMCCSC Adult EducationHoosier Hills Career CenterMCCSC Early Learning

	In what grade was the curriculum concern first identified?*
	--Please Select--Early LearningK123456789101112Adult Ed

	In what content area was the concern identified?*
	English/Language Arts    Art    Science    Math    Social Studies    Music    Other, please specify

	Please describe the curriculum concern in detail.*

	In what medium did you notice this concern?*
	Book    Workbook    Online Resource    Please provide details about the location of the concern (e.g., Book Chapter and Paragraph, Online Resource Title and Link, Page #, Photo, etc.).

	Have you spoken with the Principal?*
	Have you spoken with the Principal?* Yes No If yes, when and what was the outcome?

	Is this the first time this concern or a similar concern has been reported?*
	Is this the first time this concern or a similar concern has been reported?* Yes No

	If not the first time, how many times has it been reported?

	To whom have previous reports been made?

	When were these reports made?

	What steps might you recommend to address this concern?*