605.3E2 RECONSIDERATION OF INSTRUCTIONAL AND LIBRARY MATERIALS REQUEST FORM

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:

Name:  ___________________________________________        Date:  __________________

Address: ________________                                                                                               

City/State: ____________     Zip Code:                 Telephone:                                   

School(s) in which item is used:                                                                                

Relation to school (parent, student, citizen):                                                                

BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE

Author:                                         Hardcover:     Paperback:     Other:           

Title:                                                                                                                      

Published (if known):                                                                                               

Date of Publication:                                                                                                 

MULTIMEDIA MATERIAL IF APPLICABLE

Title:                                                                                                                      

Producer (if known):                                                                                                

Type of material (website, 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?                                                                                                                                                                                                                                                                                                                                                                                                                                                                

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

1. In your opinion, what harmful effects upon students might result from us 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?                                                                                                                                                                                                                                                                                                                                                                                                                        

1. Should the opinion of any additional experts in the field be considered?  If yes, please list specific suggestions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

1. To replace this item, do you recommend other material which you consider to be of equal or superior quality for the purpose intended?                                                                                                                                                                                                                                                                                                                                                                                                                                                            
2. Do you wish to make an oral presentation to the Review Committee?  If yes, please contact the Superintendent and be prepared at that 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.

Signature                                                                                 Date