605.3E2 - Reconsideration of Instructional Materials Request Form

Request for re-evaluation of printed or audiovisual 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                                                                  

 

AUDIOVISUAL MATERIAL IF APPLICABLE:

 

Title                                                                                                                                                                 

Producer (if known)                                                                                                                                     

Type of material (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?

                                                                                                                                                               

                                                                                                                                                               

 

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 call the office of the Superintendent

                                  (b)        Please be prepared at this time to indicate the approximate length of time your presentation will require.

                                                                          minutes.

                          No

 

 

                                                                                                                                                                    
          Dated                                          Signature

 

 

Approved   10/9/95    
Reviewed  11/15/21     
Revised