Request for re-evaluation 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 (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 contact the Superintendent
(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'll be
allowed to present to the committee, or that you will get your requested amount of time.
_____ No
Dated ____________________________ Signature_________________________________________________________
