605.3E2 - Reconsideration of Instructional and Library Materials Request Form

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

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 Superintendent

(b) Please be prepared at this time to indicate the approximate length of time your presentation will require (this is no guarantee you will be allowed to present to the committee or that you will be allowed the amount of time that you request).

Minutes.

No

Dated

Signature