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
