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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