Form S-58 Policy 6112 REQUEST TO BLOCK OR UN

Form S-58
Policy 6112
REQUEST TO BLOCK OR UN-BLOCK A WEBSITE
When you come across a website that you feel needs to be blocked or unblocked from use within the Pocatello/Chubbuck School District #25, please
use this form to make that request.
INITIATED BY:
Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
City, State, ZIP Code:
_____________________________________________________________________________
Phone Number: _________________________________ Date: _______________________
*****************************************************************************
Website:
_____________________________________________________________________________
Description:
_____________________________________________________________________________
_____________________________________________________________________________
Have you personally visited this site?
Requested Action:
☐
☐
Yes
☐
To what do you object?
No
Block
☐
Un-Block
Cite specific examples.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What do you believe might result from use of this site?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What is the educational value of this site?
_____________________________________________________________________________
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Other Comments:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ADMINISTRATIVE USE
Action:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Original: Network/Internet Assistant
Copies: Technology Coordinator and Director of Curriculum
Revised 02/04/11
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