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: _____________________________________________________________
- What brought this item to your attention?
________________________________________________________________________
________________________________________________________________________
- To what in the item do you object? (please be specific; cite pages or frames, etc.)
________________________________________________________________________
________________________________________________________________________
- In your opinion, what harmful effects upon students might result from use of this item?
________________________________________________________________________
________________________________________________________________________
- Do you perceive any instructional value in the use of this item?
________________________________________________________________________
________________________________________________________________________
- 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
