Request for re-evaluation of printed or multimedia materials to be submitted to the Superintendent, or the Superintendent's designee.
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 or Organization _________________________________________
Address of Group or Organization ________________________________________
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.
Minutes. __________________________
No _______________
__________________________________________ ________________________ Signature Dated