605.3E2 - Reconsideration of Instructional Materials Request Form

605.3E2 - Reconsideration of Instructional Materials Request Form

Request for re-evaluation of instructional 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/guardian, 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  ___________________________________________________________________

Producer (if known) _______________________________________________________

Type of material (filmstrip, motion picture, etc.) ________________________________

PERSON MAKING THE REQUEST REPRESENTS:

           Self­­ ­­­­____________­­­­­­­­­­­­___           Group or Organization _______________________

Name of Group or Organization _______________________________________

Address of Group or Organization ______________________________________

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 specific 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 _______________

 

__________________________________________            ________________________
Signature                                                                                 Dated

 

dawn@iowaschoo… Wed, 09/23/2020 - 12:56