605.3E2 - Reconsideration of Instructional and Library Materials Request Form

Request for re-evaluation of printed or multimedia material to be submitted to the superintendent.

REVIEW INITIATED BY:                                                                                                                         DATE:  ____________________________

Name:  ____________________________________________________________________________________________________________

Address:  __________________________________________________________________________________________________________

City/State  ________________________________________  Zip Code  __________________  Telephone  ____________________________

School(s) in which item is used _________________________________________________________________________________________

Relationship to school (parent, student, citizen, etc.)  ________________________________________________________________________

BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE:

Author:  ____________________________________  Hardcover:  ___________  Paperback:  ___________ Other:  ___________ 

Title:  ______________________________________________________________________________________________________________

Publisher (if known)  __________________________________________________________________________________________________

Date of Publication  ___________________________________________________________________________________________________

MULTIMEDIA MATERIAL IF APPLICABLE:

Title:  ______________________________________________________________________________________________________________

Publisher (if known)  __________________________________________________________________________________________________

Type of material (filmstrip, online resource, motion picture, etc.)  _____________________________________________________________________________

PERSON MAKING THE REQUEST REPRESENTS: (circle one)

                      Self                                                                                          Group or Organization

                     Name of Group  ___________________________________________________________________

                     Address of Group  _________________________________________________________________

1. What brought this item to your attention?
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
2. To what in the item do you object?  (please be specific; cite pages, or frames, etc.)
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
3. In your opinion, what harmful effects upon students might result from use of this item?
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
4. Do you perceive any instructional value in the use of this item?
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
5. Did you review the entire item?  If not, what sections did you review?
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
6. Should the opinion of any additional experts in the field be considered?
        __________  Yes          __________  No

   If yes, please list suggestions:

   
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
7. To replace this item, do you recommend other material which you consider to be of equal or superior quality for the purpose intended?
   ________________________________________________________________________________________________________________
   ________________________________________________________________________________________________________________
    
8. Do you wish to make an oral presentation to the Review Committee?
        __________  Yes          (a)  Please contact the Superintendent

                                              (b)  Please be prepared at this time to indicate the approximate length of time your presentation will require.  Although this is no guarantee
                                                     that you'll be allowed to present to the committee, or that you will get your requested amount of time.
                                                                                                                                      ________________ Minutes
        __________  No

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