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
