605.3E2 - Reconsideration of Instructional and Library Materials Request Form

605.3E2 - Reconsideration of Instructional and Library Materials Request Form

Request for reevaluation 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:  ________________________________________________________________________                                                                                                                                                                                   

Producer (if known) :  ___________________________________________________________

Type of material (website, online resource, filmstrip, 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?

________________________________________________________________________
________________________________________________________________________

  1. To what in the item do you object? (please be specific; cite pages or frames, etc.)

________________________________________________________________________
________________________________________________________________________

  1. In your opinion, what harmful effects upon students might result from use of this item?

________________________________________________________________________
________________________________________________________________________

  1. Do you perceive any instructional value in the use of this item?

________________________________________________________________________
________________________________________________________________________

  1. 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

______  No     (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 will be allowed to present to the committee or that you will get your requested amount of time.

                                 ____________________________________________________  Minutes

 

_______________________________                      ____________________________________
Dated                                                                                              Signature

 

dawn.gibson.cm… Wed, 12/21/2022 - 15:20